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CDEmiGHT DEPOSIT. 



Regional Anesthesia 



(VICTOR PAUCHET'S TECHNIQUE) 



BY 



B. SHERWOOD-DUNN, M.D. 

Officier d'Academik; Surgeon (Colonel) Service de Sante Militaire de: 
Paris; Physician to the Cochin Hospital. 



WITH 224 FIGURES IN THE TEXT 




PHILADELPHIA 
F. A. DAVIS COMPANY, Publishers 

English Depot 
Stanley Phillips, London 

1920 






COPYRIGHT, 1920 

BY 

F. A. DAVIS COMPANY 



Copyright, Great Britain. All Rights Reserved, 



oAN -8'id2D 



PRESS OF 

F. A. DAVIS COMPANY 

PHILADELPHIA, U.S.A. 



©Cl.A559y^9 



PREFACE. 

For thirty years Professor Reclus, of the 
Paris Faculte, preached and practised local anes- 
thesia. His method consisted in infiltrating the 
tissues upon which he proposed to operate with a 
weak solution of cocaine — then proceeding with 
the operation. 

This procedure is well known in France, and 
is often employed in minor operations. 

Regional anesthesia differs widely from the 
method of Reclus. Instead of applying the anes- 
thetic to the terminals of the nerves, it is injected 
at the point of the origin of the nerve, or along 
the trunk near the point of origin, so that the 
whole region supplied by the nerve and its branches is 
anesthetized. All the major as well as the most deli- 
cate minor operations can be performed in this way. 
The method has gained many adherents since 
1914, and its growing popularity has led us to 
believe that an exposition of it would be wel- 
comed by the American profession. 

Professor Victor Pauchet is acknowledged to 
be the leading exponent of regional anesthesia in 
France, and this . book constitutes a resume of his 

(iii) 



iv PREFACE. 

writings upon this subject, together with those of 
P. Sourdat and J. Laboure. In addition there is 
included the latest experiences of Pauchet and the 
writer, together with Pauchet's recommendations, 
inserted during his revision and amplification of 
the manuscript before its transmission to the pub- 
lishers. 

I wish to acknowledge my indebtedness to Dr. 
Emilie Jane and Miss Frances Johnson, R. N., 
and to express my high appreciation of the assist- 
ance which they have rendered me in the prepara- 
tion of this work for publication. 

B. Sherwood-Dunn. 



CONTENTS. 



CHAPTER I. 

PAGE 

General Considerations 1 

Advantages of Regional Anesthesia 1 

Disadvantages of Regional Anesthesia 5 

CHAPTER H. 

Armamentarium 12 

Syringes 12 

Needles 12 

Anesthetic 14 

General Technique 17 

CHAPTER HI. 

Cranial Operations Zl 

Treatment of Large Wounds in the Soft Tissues, or of Com- 
pound Fractures of the Skull 40 

Removal of Malignant Tumors of the Cranium, with Bone 

Resection 42 

Trephining the Temporal Region 43 

Exposure of the Cerebellum 46 

CHAPTER IV. 

Anesthesia of the Head and Neck 48 

Anesthesia of the Gasserian Ganglion 48 

Anesthesia of the Trigeminal Nerve Distribution 57 

Regional Anesthesia in Rhinology 80 

Regional Anesthesia in Otology 85 

Regional Anesthesia in Ophthalmology 91 

Regional Anesthesia in Dental Surgery 94 

Regional Anesthesia of the Face and Jaws 97 

Regional Anesthesia of the Tongue, Floor of the Mouth, Ton- 
sils and Palate 105 

Regional Anesthesia in Operations of the Neck 109 

(v) 



vi CONTENTS. 

CHAPTER V. 

PAGE 

Anesthesia of the Thorax and Abdomen 128 

Intraspinal Anesthesia 128 

Nerve-trunk Anesthesia ....... 136 

Paravertebral Anesthesia 144 

Paracentesis of the Pleural Cavity 153 

Thoracotomy for Empyema with Costal Resection 153 

Resection of the Second to the Fifth Costal Cartilages for 

Rigidity of the Thorax 155 

Operations upon the Sternum , 158 

Thoracotomy for Abscess of the Lung, etc 158 

Operations for Tumor of the Breast 160 

Operations in the Axilla 162 

Abdomen 162 

Operations upon the Stomach 165 

Median Hypogastric Incision 167 

Operations in the Iliac Fossa 169 

Umbilical Hernia 186 

Inguinal Hernia 188 

Femoral Hernia 195 

Operations upon the Kidneys 198 

Operations upon the Biliary Passages 199 

CHAPTER VI. 

Anesthesia of the Genito-urinary Organs and Rectum 200 

Anterior Sacral Anesthesia (Pre-sacral) 205 

Anesthesia through the Sacral Foramina — Trans-sacral An- 
esthesia 207 

Operations upon the Bladder \ 212 

Operations upon the Testicles and Scrotum 214 

Operations upon the Penis 217 

Operations upon the Posterior Urethra 219 

Operations upon the Prostate 220 

Operations upon the Vulva and Vagina 220 

Operations upon the Anus 224 

CHAPTER VII. 

page 

Anesthesia of the Extremities 230 

Upper Extremity 232 

Operations upon the Hand 245 

Operations upon the Forearm 258 



CONTENTS. vii 

Anesthesia of the Extremities (continued). 

Upper Extremity, Operations at the Elbow 261 

Operations upon the Arm 263 

Operations upon the Shoulder 264 

Lower Extremity 265 

Operations upon the Toes 270 

Operations upon the Entire Foot 272 

Operations upon the Knee 274 

Operations upon the Soft Part of the Thigh 277 

Conclusions 283 

Index 285 



CHAPTER I. 

GENERAL CONSIDERATIONS. 
Advantages of Regional Anesthesia. 

Anesthesia by injection possesses, as compared 
with anesthesia by general narcosis, advantages of 
such cardinal importance that, at the A^ery outset, 
the reader's attention should be directed to them 
as ample justification for the time, labor and 
special education required to become sufficiently 
expert in its application to permit of its adoption 
for general employment. 

Lozv Mortality Risks. — Since the concentrated 
solutions of cocaine have been replaced by weak 
solutions of the less toxic agents, such as sto- 
vaine, novocaine, procaine, etc., death from local 
or regional anesthesia has disappeared from sur-, 
gical practice. The writer is unacquainted with 
a single case of death due to the employment of 
the last named anesthetics. 

The relative rarity of death from narcosis 
(chloroform, i in 2000; ether, i in 5000) may 
make this advantage seem insignificant; but it is 
only necessary for an operator to lose one patient 
by narcosis, to have this apparently insignificant 
advantage brought forcibly to his attention. 

(1) 



2 REGIONAL ANESTHESIA. 

Reduction of Post-operative Dangers. — General 
narcosis, aside from its mortality, produces com- 
plications which are of great importance because 
of their frequent occurrence. They include chiefly pul- 
monary complications, caused or aggravated by 
etherization, and alterations in the liver and kid- 
neys through the action of ether, and particularly 
of chloroform. Rapid degeneration of the liver 
and kidneys following surgical operations is often 
attributed to shock or post-operative infection, but 
the fact that these accidents are eliminated by 
regional anesthesia would indicate that they are 
directly due to the action of the compounds used 
in general narcosis, and the superiority of regional 
anesthesia is made strikingly apparent in opera- 
tions upon subjects suffering with chronic jaun- 
dice or renal insufliciency. The nausea and vomit- 
ing, which often continue for forty-eight hours 
after an operation and are such prominent factors 
in reducing the vital forces — especially in patients 
w^th strength already at the lowest ebb — are often 
the determining cause of death. These trouble- 
some conditions are eliminated in regional anesthesia. 

Diminution of Shock. — The reflex action of 
traumatism, the unconscious suffering of a patient 
even under the full influence of narcosis, is trans- 
mitted to the nerve centers, provoking disturbances 
which, repeated, result in certain alterations in the 
neurons, and these alterations constitute shock. 

Local or regional anesthesia secures a com- 
plete physiological section of the nerves and sup- 



GENERAL CONSIDERATIONS. 3 

presses completely this influence upon the nerve 
centers. 

This fact has been so fully demonstrated that 
Crile (of Cleveland) practises local and regional 
anesthesia in all of his major operations, even 
when employing general narcosis with nitrous 
oxide. If comparison is made between a series 
of operations for cancer of the stomach under 
narcosis and a series under regional anesthesia, 
the relative condition of the patients subsequently 
offers a striking confirmation of the innocuousness 
of the latter procedure. 

Absence of Danger from Asphyxia. — Adminis- 
tration of ether or chloroform is generally at- 
tended by greater or less respiratory disturbances. 
Onlookers often have their attention attracted by 
the patient's difficulty in breathing, due generally 
to mucus collecting in the mouth and nose, espe- 
cially in the Trendelenburg position. Not infre- 
quently the operator's attention is arrested by the 
same difficulty. All of this is absent in injection 
anesthesia. 

Operations upon the respiratory tract, or in 
its vicinity, are greatly simplified and facilitated. 
The patient assumes whatever position is desired, 
being perfectly conscious. He can at will arrest 
his breathing, suppress a cough, or expectorate if 
need be. This is of valuable assistance in opera- 
tions upon the pleura, larynx, neck, etc. In oper- 
ations for goiter it safeguards the recurrent laryn- 
geal nerve by allowing the patient to speak, thus 
calling attention to the nerve. 



4 REGIONAL ANESTHESIA. 

Special Advantages in Certain Operations. — 
The fan-like distribution of the nerves after they 
leave the large nerve trunks permits the per- 
formance of extensive operations once the trunk 
has been anesthetized. Thus a bronchial tumor, 
or the cervical glands can be removed, or total 
laryngectomy or external esophagotomy performed 
after preliminary infiltration of the cervical plexus. 

Nephrectomy can be painlessly performed after 
paravertebral infiltration of six intercostal and 
two lumbar trunks; not only are the parietes 
rendered insensible, but the kidney can be sutured 
or the pedicle liberated and ligated without pain. 
The same advantage attaches in operations upon 
the liver and stomach. The rectum can be excised 
after injecting through the sacral foramen. 

Compared with the method of local infiltration, 
practised by Reclus, regional anesthesia possesses 
the following advantages : 

(i) The anesthesia is entirely distinct from the 
operation proper, being instituted beforehand, and if 
possible, by an assistant in an adjoining room. Con- 
sequently, successive operations can be performed 
without loss of time. 

(2) Once the nerve or nerves have been properly 
anesthetized, the anesthesia contimies complete for 
from one and one-half to tzuo and one-half hours 
and the operation is never interrupted to make addi- 
tional injections as is often the case in infiltration 
•anesthesia. 

(3) It obviates all danger of necrosis of the tis- 
sues, such as sometimes occurs in local infiltration 



GENERAL CONSIDERATIONS. 5 

where a section of the skin is mobihzed in a plastic 
operation to cover, a denuded surface and is nour- 
ished only by a narrow pedicle. 

Disadvantages of Regional Anesthesia. 

Special Training Required. — Some training in 
the practical method of application is required to per- 
mit of successful practice of this procedure — though 
not more than is necessary for the execution of any 
of the simpler types of surgical operations. 

As the simplest and most rapid procedure for 
securing the necessary experience we advise that 
the operator, after reading the detailed descrip- 
tions herein presented, first practise finding upon 
the skeleton, with needles of varying lengths, the 
cranial, spinal, intercostal and sacral nerve for- 
amina. 

When he has become familiar with the depths 
and directions of the various punctures through ex- 
ercises upon the skeleton, the student of the method 
may then repeat the various operations upon the 
cadaver, using the longer and coarser needles and a 
fluid containing India ink. Dissection of the more 
diflicult regions, after such experimentation, will 
disclose any faults and soon draw the operator's at- 
tention to any necessary corrections. Too much time 
need not be spent in this experimental work, how- 
ever, before the operator begins upon the living sub- 
ject, as no harm results from the injection of the 
fluid. But little actual experience is required for the 
surgeon to become confident and adept in finding the 



6 REGIONAL ANESTHESIA. 

nerve trunks, this being facilitated by the more or 
less pronounced sensation referred to the terminal 
distributions when the point of the needle touches 
the nerve trunk, or by the insensibility of the sur- 
faces supplied. 

It will assist the operator in rapidly gaining con- 
fidence and skill if he will use at first a larger amount 
and a stronger solution and infiltrate a more exten- 
sive area. 

Necessity of Gentleness and Skill in Operative 
Technique. — It is obvious that where an operation 
must be done with the complete consciousness and 
oftentimes in full view of the patient, a gentle, un- 
hurried, and quiet technique is imperative and is 
conducive to a greater degree of satisfaction to 
the patient, with better results. 

Some operators are accustomed to break up ad- 
hesions and carry out many surgical maneuvers with 
their hands and fingers. With injection anesthesia 
in abdominal operations especially, all pulling, tear- 
ing, and rough treatment should be avoided, as even 
with complete insensibility of the parts the patient 
cannot but be cognizant of the methods employed, 
and any such treatment produces an unfavorable 
mental impression which is prejudicial to final suc- 
cess. The scalpel and scissors should be used for all 
necessary separation of parts. Again, it is the habit 
of some to employ in their operations a variety of 
retractors, which are often the cause of unnecessary 
traumatism to the parts. This may also be said of 
the employment of an unnecessary number of pres- 
sure and rat-tooth forceps. 



GENERAL CONSIDERATIONS. 7 

It must not be overlooked that a difference exists 
between sensation and pain; unnecessary pulling 
and handling of parts produces a disagreeable sen- 
sation which is likely to cause complaint on the part 
of the patient. 

The more gently and quickly the operator pro- 
ceeds, the greater will be his measure of operative 
success. 

Objection that the Method Procures only a Partial 
Anesthesia. — In regional anesthesia it has been our 
experience that, out of 20 cases, 12 are completely 
insensible; 7 are sufficiently insensible to all neces- 
sary manipulations to permit of the operative pro- 
cedure without serious complaint on the part of the 
patient; while i case out of 20 is found insufficiently 
anesthetized and must be given a little ethyl chloride 
to OA^ercome the deficiency. Even in this event the 
quantity of inhalation anesthetic required is very 
slight. 

The value of regional anesthesia is demonstrable 
by comparison, chiefly with general narcosis. The 
reader need only be reminded of the distressing ex- 
periences which attend the beginning and the close 
of the latter procedure, and but little experience with 
the former will convince any expert operator of its 
marked superiority. Apart from the distressing 
period of vomiting which follows general narcosis, 
the after pains complained of during the succeeding 
day and night are usually greatly diminished in 
regional anesthesia, and after nephrectomy, lapa- 
rotomy, and facial operations a lasting condition of 
hypoanesthesia may often be noted, which renders 



8 REGIONAL ANESTHESIA. 

the injection of morphine or other narcotic during 
the succeeding twenty-four hours unnecessary. 

True, the patient will often complain at some 
time or other during the course of the operation. 
One says the table is too hard; another asks if the 
operation will not soon be finished; many complain 
of suffering because they confound sensation with 
pain. One of our patients cried out when he heard 
a fragment of his rib fall into the slop basin. These 
are minor inconveniences which it is well to be aware 
of in order to be prepared for them when they be- 
come manifest. The table should be well padded. 
In nervous and sensitive cases it is advisable to 
blindfold the patient's eyes and to stop the ears with 
cotton. 

Before all operations the 'patient should be given 
an injection of scopolamine-morphine, which not 
only does not interfere with, but rather assists the 
method. Absolute silence should be maintained in 
the operating room. 

Necessarily the operator must have become 
perfected in the details and technique of the regional 
form of anesthesia. Any operator who, in the anes- 
thetization of his patients, has had to rely upon the 
services of different assistants, knows how seldom 
a good one is found. The number of patients who 
are insufficiently or imperfectly brought under the 
anesthetic and bear down or resist during the course 
of the operation is legion, while not infrequently 
cases absorb too much of the anesthetic, causing the 
operator to discontinue his work while the patient 
is brought back from the danger line. It is not too 



GENERAL CONSIDERATIONS. 9 

much to ask, therefore, that the operator intending 
to make use of regional anesthesia should carefully 
and completely train himself in the details of the 
procedure and persevere in his technical practice 
until he has reached a satisfactory degree of perfec- 
tion, just as he does in any and every other depart- 
ment of medical practice. 

An important feature that should never be lost 
sight of is the psychology of the patient. Those who 
accept the method reluctantly, and are anxious, nerv- 
ous, and hyper-sensitive, are the difficult subjects; 
most of these, however, once the operation has been 
satisfactorily concluded, express themselves as com- 
pletely satisfied. 

On the other hand, there are those who, familiar 
with the distress of the after-effects of general nar- 
cosis, welcome the new mode of procedure and make 
most satisfactory subjects. The mental attitude of 
the patient has almost as much to do with the suc- 
cess of the operation as the ability of the operator. 

The -Time Element. — About the same time is 
consumed in the administration of regional anes- 
thesia as in that of general narcosis. About ten 
or fifteen minutes are required for an experienced 
assistant to perform the necessary injections in the 
former procedure, and another ten minutes must 
then elapse for the full effect to become estab- 
lished. About the same length of time is re- 
quired to obtain the complete effects of inhalation 
anesthesia. 

Where the operator is dealing with a private 
case, it is not often that a few moments more or less 



10 REGIONAL ANESTHESIA. 

will particularly interfere with the type of technique 
he may select, that which is best in his opinion 
governing the choice. 

In hospital service, where several cases are to be 
operated upon, it is essential to have an experienced 
assistant for the advance preparation of the cases. 
This likewise applies in the administration of a 
general anesthetic. 

In any event, the loss of a few moments' time is 
not to be considered in comparison with the benefits 
to the patient that attend the regional form of 
anesthesia. 

The Claim that Regional Anesthesia is not Equally 
Adapted for all Operations. — The beginner in 
regional anesthesia may better satisfy both himself 
and the patient by giving ethyl chloride, ether, or chlo- 
roform to complete the anesthesia if there is complaint 
to any degree. 

Mixed anesthesias, although not attractive in 
theory, cause less shock than simple narcosis. 

If a preparatory injection of morphine-scopola- 
mine is administered before the introduction of the 
procaine-suprarenin and the operation is completed 
with the aid of the inhalation narcotics referred to, 
the patient will be affected less than by simple nar- 
cosis, i.e., he will be less affected by three agents than 
by one. For this a theoretical explanation is avail- 
able, but such explanation is not so important as the 
fact itself which has been learned by actual ex- 
perience. 

In trephining operations, goiter excisions, total 
laryngectomies, prostatectomies, operations for hem- 



GENERAL CONSIDERATIONS. H 

orrhoids, radical cure of hernia, and costal resec- 
tions, regional anesthesia is a most gratifying pro- 
cedure. With increasing experience, furthermore, 
the operator will learn the details of technique that 
render this form of anesthesia applicable to any and 
all operations. 



CHAPTER 11. 



ARMAMENTARIUM. 



Syringes. — The operator should have at his dis- 
posal Luer's all glass morphine syringe of i- to 2- mil 
capacity, and also a metal and glass syringe of 10- 
mil capacity. 

]\Iy earlier experience was with the Record 
syringe, which is very serviceable, but more lately I 
have been led to substitute the Collin all metal 
syringe (Fig. i), which is to be preferred in that it 
is both short, powerful, and unbreakable. The syringe 
should be thoroughly water tight and provided at its 
top with lateral handles by means of which a firm 
hold can be secured. 

Needles. — These should be of small caliber, with 
a short-beveled point. The smaller the caliber of the 
needle, the less painful its introduction. Needles of 
the smallest caliber and with long, fine points 
should be particularly employed for the formation 
of the dermal wheals later to be described. 

Platinum needles are expensive and soon be- 
come blunted at the point. Steel needles are finer 
pointed and remain sharp longer, but are prone 
to rust and are easily broken. I have found it 
best to employ either fine steel, or nickel needles. 
The latter remain sharp and in good condition the 
longest. The junction between the nozzle of the 
(12) 



ARMAMENTARIUM. 



13 



syringe and the needle must permit of no leakage, 
the needle remaining in situ while the syringe is 
repeatedly removed for refilling. The smooth 







Fig. 1. — A 10-mil metal syringe of Collin make, short, 
strong, unbreakable, handy and with graduated plunger rod. 
The lateral socket enables the operator to make injections 
parallel with the surface while using a straight needle. 



14 REGIONAL ANESTHESIA. 

socket type should be chosen rather than the screw 
or bayonet form. 

We employ only the straight form of needle. 
It is less expensive and more easily obtained, and 
when once one is accustomed to its use, it answers 
every purpose. 

There should be provided needles of four 
lengths, viz., 3, 6, 9, and 12 centimeters (Fig. 2). The 
3-centimeter needle is used in making the dermal 
wheals. It should be sharp pointed. The 12- 
centimeter needle is seldom used — chiefly for pre- 
sacral injections. The 6- and 9- centimeter needles 
serve for all general purposes. 

To mark the exact depth to which the needle 
is to be introduced, the operator may make a 
shield from a piece of boiled cork or a square 
of rubber sheeting, to be adjusted upon the needle 
at the point desired. 

The instruments and receptacles for the solu- 
tion should be sterilized in plain boiling water, 
without addition of any chemical agent whatever. 

Anesthetic. — As anesthetic we have been using 
neocdine-siirrenine (Corbiere), a French prepara- 
tion which replaces with perfect satisfaction the 
German product novocaine-adrenalin. In prepar- 
ing a considerable amount of the solution, to be 
kept for some hours, it is best to use the pure 
procaine,^ to which can be added immediately be- 
fore use the required quantity of adrenin. 



1 Procaine being the term now in general use in the United States 
in place of neocaine or novocaine, this term will be regularl}^ employed 
hereinafter. 



ARMAMENTARIUM. 15 

The formulas of the mixtures used are as fol- 
lows: (i) 25 drops of I to 1000 adrenin solu- 
tion to 200 mils of >4 per cent, procaine solution; 



Fig. 2. — Four steel needles, respectively, 12, 9, 6, and 3 centi- 
meters in length. Each needle is provided with a mandril. 
Actually the needles are twice as fine as they are represented 
in this illustration. 



(2) 25 drops of adrenin to 100 mils of i per 
cent, procaine; (3) 25 drops of adrenin to 50 mils 
of 2 per cent, procaine; (4) 25 drops of adrenin 



16 



REGIONAL ANESTHESIA. 



solution to 25 mils of 4 per cent, procaine. 
Twenty-five drops of the adrenin solution is the 
equivalent of i milligram of adrenin. 

We use the 4 per cent, solution but seldom, 
for the cranial nerves and brachial plexus; the 2 
per cent, solution frequently, as a rule for the 
nerve trunks; but the i per cent, and especially 




Fig. 3. — From left to right, an ampoule of saline solution 
for dissolving the procaine ; a tube containing 2 capsules of 
procaine in powder form and 3 sealed flasks containing 150 
grams of y^ per cent, solution. 



the Yi per cent, solutions are those most com- 
monly employed, the latter for all infiltrations. 

It is far cheaper to prepare the solution as re- 
quired than to buy it ready made. 

The adrenin and procaine come in glass am- 
poules. On the evening of the day preceding the 
operation these are dissolved in boiled salt solu- 
tion. Even more convenient are the procaine tab- 
lets which can be dissolved in boiled salt solution 



ARMAMENTARIUM. X7 

and kept nntil needed for use, when the required 
amount of adrenin is added. 

It is inadvisable to attempt to sterihze the 
solution after the mixture has been made; this 
should be done beforehand. The procaine adrenin 
should be added to a hot solution (35° C.) to in- 
sure its ready dissolution. 

The high percentage solutions should be in- 
jected very slowly, and in amounts never exceed- 
ing 20 to 40 mils of the J^ per cent, solution. 
Wt have employed, however, as much as 300 mils 
without any harmful effect. 

In removal of the breast for cancer, as much 
as 250 to 300 mils may be employed; most of it 
escapes after the primary incision has been made. 

For anesthetizing the viscera, and especially the 
peritoneal ligaments, the omental tissues, the meso- 
appendix, the mesentery, and the sero-vascular 
pedicles, we often employ (following the advice 
of Crile, of Cleveland) a i per cent, solution of 
quinine and urea hydrochloride,^ injecting as 
much as 100 grams in addition to the solution of 
procaine-adrenin already used. 



General Technique. 

Theoretically, regional anesthesia and anesthe- 
sia by infiltration, according to the procedure of 
Reclus, are fzuo different methods. Practically, 
neither of them excludes the other, but, in fact, 



1 The product termed by Corbiere urocaine. 

2 



18 REGIONAL ANESTHESIA. 

they supplement each other and are often em- 
ployed in combination. 

The principle of regional anesthesia is, not to 
infiltrate the field of operation or surrounding tis- 
sues, but to secure insensibility by directly inject- 
ing the nerves distributed to the region or tissues 
surrounding these nerves. To each region cor- 
responds a special technique, appropriate for the 
insensibilization of the nerves in that region, and 
with which the operator must be familiar in order 
to succeed. 

Necessity of Perfect Asepsis in Regional Anes- 
thesia. — In making the injections, the operator 
proceeds without gloves, but with hands well dis- 
infected, as for an ordinary minor operation. The 
instruments and solution must be sterilized. Care 
is taken not to dip the syringe into the glass re- 
ceptacle containing the solution, particularly if the 
syringe has come in contact with the fingers of the 
operator and the patient's skin. A special needle 
is reserved for drawing up the fluid into the 
syringe. It should be constantly borne in mind 
that ungloved hands are never aseptic any more 
than is the patient's skin. 

In practice, the two methods, nerve-block- 
ing and infiltration, are usually employed together, 
the one aiding and completing the other. 

With few exceptions, e.g., anesthesia of the 
meso-appendix with urocaine before its section, or 
anesthesia of the omental tissues, complete induc- 
tion of anesthesia precedes the operative pro- 
cedure. No injection should be made during the 



ARMAMENTARIUM. 19 

Operation, which is performed as though the pa- 
tient were under general anesthesia; the anesthe- 
sia should be complete when the patient is brought 
to the surgeon, and there should be no more ques- 
tion of it during the operation. 

The method does not in any way prolong the 
duration of the operation, nor does it leave the 
operative field or the incision any longer exposed 
to the air. 

Preparation of the Field of Operation. — Before 
the injections are begun, the skin of the field of 




Fig. 4. — A 5-mil syringe of metal and glass. 

operation should be disinfected with a 5 per cent. 
tincture of iodine. When the injections have been 
completed the region should be rubbed with alco- 
hol, which will remove the few drops of liquid 
injected and the excess of iodine. Next come the 
final preparation of the patient, the covering of 
the operative field, and the preparation of the 
operator and his assistant — during w^hich time the 
tissues will have become completely anesthetized. 

The Injections. — The syringe (Fig. 4) is held 
with the thumb and the second and third fingers 



20 REGIONAL ANESTHESIA. 

of the right hand (Fig. 5). By virtue of the 
flexibihty of the operator's wrist, all pressure 
other than that in the direct line of the needle 
is obviated, to avoid breaking of the needle. The 
latter should never be inserted down to its flange. 




Fig. 5. — Shows the manner of holding the syringe 
during injection. (Reclus.) 



The plunger should be pushed home during the 
introduction or the removal of the needle, the two 
acts being simultaneous {continuous injection of 
Reclus). The minimum quantity of ^ per cent, 
solution to be injected is i mil per centimeter of 
distance; for the i per cent, solution, slightly less. 



ARMAMENTARIUM. 21 

The slight edema resuhing from the subcutane- 
ous injection raises the overlying skin, and the 
region injected, rendered ischemic by the adrenin, 
becomes definitely pale. 

Difficulties arising from edema of the super- 
ficial tissues may be obviated by commencing with 
deep injections. 

Skin Wheals. — In infiltrating a given region, 
it is often necessary to make successive injections 



^..........^...^^^^^^-//-----/--^ 




Fig. 6. — Formation of the dermal wheal. (Pauchet.) The 
bevel of the needle point is directed upward and should dis- 
appear entirely in the dermis before the intradermal injection 
is made. 



with needles chosen progressively longer. Again 
it is indispensable to mark beforehand the sites 
for these injections by the formation of "intra- 
dermal wheals'' which will render the skin insen- 
sitive to the introduction of the needle. The 
wheal consists essentially of an intradermal infil- 
tration of small diameter (Fig. 6). 

A fine, short needle mounted on a syringe filled 
with J^ per cent, solution is introduced almost 
parallel with the skin surface, with the bevelled 



22 REGIONAL ANESTHESIA. 

edge upward, directly into the thickness of the 
skin. As soon as the opening of the needle has 
disappeared, the plunger is pushed down to drive 
in a little of the solution. A white swelling in- 
stantly forms in the tissues, which take on the 
aspect of ''orange skin.'' One or more wheals, ac- 
cording to requirements, are thus marked out, and 
through them the needles are subsequently intro- 
duced for all the necessary injections. 

Each injection should be made into the skin 
proper, without passage through into the subcu- 
taneous cellular tissue, which is made evident by 
disappearance of resistance to the needle. If the 
skin of the region is delicate and movable, a fold 
of it should be taken up between the left thumb 
and index finger and the needle introduced at the 
top of this fold, meanwhile firmly held. The pain 
is very slight and evanescent, disappearing as 
soon as the anesthetic solution has been injected. 

Injection at Right Angles. — When it is neces- 
sar}^ to make an incision at right angles, as for 
blood transfusion, the intradermal injections of 
Reclus are superfluous, subcutaneous injection be- 
ing sufficient to anesthetize the subcutaneous tis- 
sue. An intradermal wheal is made at one end 
of the incision; then, with a syringe provided with 
a long needle, an injection is made through the 
wheal, under the skin, the needle being inserted 
parallel to the surface in the subcutaneous tissues 
to the full length of the proposed incision or the 
distance that the needle permits. Inadvertent 
emergence of the point of the needle from within 



ARMAMENTARIUM. 



23 



outward should be avoided, as it is more painful 
than entrance of the needle from without in. 




Fig. 7. — Subcutaneous infiltration of a straight band of skin 
through two dermal wheals at either extremity. {Rectus.) A 
needle traverses the dermal wheals without pain when the in- 
jection is made slowly. One mil of procaine-adrenin solution to 
each centimeter of distance. The illustration presents both a 
front and a side view, with curved or angular incisions. 



After a few minutes the skin covering the in- 
jected tissue will have become insensible, the solu- 
tion having anesthetized not only the subcutaneous 




Fig. 8. — (A) The injections can be made through 2 wheals 
or 1 wheal. (B) Continuous line of injections, as indicated 
by the directions of the arrows. (Pauchet.) 



tissue, but also the nerve filaments of the adjacent 

skin. This is the simplest form of local anesthesia. 

If one injection or one needle-length is not 

sufficient, one should make two wheals, one at 



24 REGIONAL ANESTHESIA. 

each extremity of the proposed incision — or as 
many as may be required — and infiltrate from the 




Fig. 9. — Injections surrounding a field of operation. (Rec- 
lus.) The 6 wheals are united by bands of infiltration as in- 
dicated by the arrows. 

two ends (Fig. 7). Curved incisions or injections 
at right angles require an injection at the summit 
of the curve or angle, or two injections (Fig. 8). 




Fig. 10. — Shows the method of infiltrating the curved sur- 
face of the forearm through 4 dermal wheals, each wheal be- 
ing placed at the summit of the curve. (Pauchet.) The 
injections are made in the directions shown by the arrows. 

The curvature of the body surface prevents the 
penetration of a needle at right angles into the 



ARMAMENTARIUM. 25 

skin at a single injection. Thus, in injecting the 
subcutaneous tissues around the forearm, four 
wheals through each of which the needles are 
entered from both sides (Figs. 9 and 10) are 
required. 

Infiltration of a subcutaneous band perpendicu- 
lar to the axis of the limb anesthetizes not only 
the skin immediately covering the injected tissue. 



Fig. 11. — Infiltration of a subcutaneous surface by injec- 
tions radiating from dermal wheals 1 and 2 (for the removal 
of skin grafts, excision of a chancroid, etc.). (Pauchet.) 



but also all the subcutaneous tissues situated dis- 
tally to the injected region (circular anesthesia). 
Surface Iniiltrafion. — This consists in the in- 
filtration of an area of subcutaneous tissue by i, 
2, or more vrheals. Through each of these points 
a long needle is introduced in all directions, anes- 
thetizing the whole of the cutaneous surface bounded 
by the wheals. This procedure is serviceable for 
the preparation of Thiersch skin grafts (Fig. 11). 



26 REGIONAL ANESTHESIA. 

For the removal of skin tumors, subcutaneous 
infiltration of the base of the neoplasm suffices, 
without injection of the tumor itself (Fig. 12). 

Anesthesia of Mucous Membranes, — The same 
directions hold good in the case of mucous mem- 
branes, but the wheals are unnecessary. One simply 
makes a sub-membranous injection, which renders 
the adjacent area of mucous membrane insensible. 

Circular Injections. — In certain parts of the 
body the sensory nerves of the skin and of the 




Fig. 12. — Infiltration of the pedicle of a skin tumor 
(molluscum). (Pauchet.) 

fascia are continuous. Large portions of the body 
surface do not have special nerves from the sub- 
aponeurotic region. Hence it is not always neces- 
sary, in anesthetizing the skin and subcutaneous 
tissues, to inject the cellular tissue; in many in- 
stances a subcutaneous injection surrounding the 
latter suffices. This is what is termed circular 
injection (Fig. 13). At i and 2, two injections 
are made; the subcutaneous tissue is infiltrated 
from I to 3, I to 4, 2 to 3, and finally from 2 
to 4, so that the operative field is surrounded by 



ARMAMENTARIUM. 



27 



a subcutaneous wall of infiltration in the form of 
an elongated lozenge. The long diameter of the 
lozenge-shaped area corresponds to the direction 
of the incision to be subsequently made. Injec- 
tions may instead be made at 3 and 4, if it is more 




Fig. 13. — Subcutaneous quadrilateral infiltration through 
1 and 2, in the shape of a lozenge, 1, 2, 3, and 4, following 
the direction of the arrows. (Reclus.) 



convenient. The wall surrounding the operative 
field may, as desired, be made in the shape of a 
square, circle, etc. The number of wheals to be 
prepared for the injections depends upon the 
shape and dimensions of the operative field (Fig. 9). 
In some parts of the body, the sensory nerves 



28 



REGIONAL ANESTHESIA. 



run a prolonged subcutaneous course, supplying 
both the surface and the deep tissues. As regards 
the upper part of the head, the sensory nerves of 
the skin, pericranium, periosteum, and bones all 
course through the subcutaneous tissue at the 
level of the base of the cranium and forehead. 




Fig. 14. — Anesthesia for tapping, as in ascites or pleurisy, 
or for the introduction of a radium tube into a tumor. 
(Rechis.) 



Consequently a simple circular subcutaneous injec- 
tion will desensitize large areas on the head, in- 
cluding the bones. Anesthesia of a finger is in- 
stituted on the same principle. The subcutaneous 
tissue of the first phalanx contains all the nerves 
of the finger. If a ring be injected around the 
base of the finger, the entire finger will be desen- 
sitized. 



ARMAMENTARIUM. 29 

Deep Infiltration. — Simple circular subcutaneous 
injections are adequate only in parts of the body 
in which the nerve supply is disposed as in the 
parts above mentioned. They are not adequate when 
the nerve supply is deeply seated. Thus, on the 
chin, circular injection of an operative field in the 
center of which emerges the mental nerve would 
yield only an incomplete anesthesia. One of the 
primary essentials in inducing regional anesthesia 
is a systematic infiltration of any thick bed of 
tissue composed of different layers. An example 
of such anesthesia in its simplest form is that of 
the line of puncture in ascites or pleural effusion 
(Fig. 14). 

The point of the injection is marked by a 
wheal, a needle of a convenient length inserted, 
and an injection made without interruption down 
to the subpleural or subperitoneal tissues. The 
pleural and the peritoneal nerves require separate 
infiltration because they course in the subpleural 
or subperitoneal tissues. 

Infiltration by Layers. — A systematic infiltra- 
tion of a mass of tissues is that which will act 
upon all the layers of tissue therein contained 
(Fig. 15). One should begin with deep injections 
and finish with subcutaneous ones. The needle, 
through a wheal, is inserted in a perpendicular 
direction to the deepest point. It is then brought 
up to the subcutaneous tissue and inserted again, 
injecting obliquely toward the middle of the tis- 
sue-mass to be infiltrated, and so on. The last 
injection is made in a parallel direction under the 



30 



REGIONAL ANESTHESIA. 



skin. The fluid is injected continuously during 
the introduction and withdrawal of the needle. If 
the length of the needle will allow, a single wheal 
at one extremity or in the middle suffices. 

At no point in the body are subperiosteal in- 
jections necessary for desensitization of the perios- 
teum, which receives its nerves from without and 
becomes desensitized through the influence of the 
fluid in the tissues which cover it. 




Fig. 15. — Osteotomy of the femur. (PaucJiet.) Anesthesia 
of the diaphysis. Make two wheals, 1 and 2. From these 
two points make the injections above and below as shown by 
the arrows, forming a liquid sheath round the periosteum. If 
the ears of the patient be stopped with cotton, one may saw 
or break the bone without causing him pain or nervous dis- 
turbance. 



Infiltration of thick masses of tissues, as just 
described, demands a certain amount of practice. 
One must learn to feel with the point of the 
needle. One must know at every instant which 
anatomical layer is being entered. The hand soon 
becomes accustomed to recognizing when the needle- 
point is traversing a resistant layer and when it 
again passes into a layer of soft tissues. Injec- 
tion through the muscular aponeuroses generally 
causes slight pain. Therefore, one should inject 



ARM AM EX T ARl UM. 



31 



the fluid progressively as the needle is being in- 
troduced, following the method of Reclus. By 
this procedure injection of a large amount of the 
anesthetic into a vein is obviated, while at the 
same time, continuous injection insures an equal 
distribution of the solution. When an injection 




Fig. 16. — Infiltration of a layer of soft tissue through der- 
mal wheals 1 and 2. (Pau-chet.) The injections follow the 
direction of the arrows down to the bone, the last made being 
those entering the subcutaneous cellular tissue. 



in the proximity of large vessels is required, it 
is best to introduce the needle independently of 
the syringe and to inject the fluid only if blood 
fails to flow from the needle lumen. Puncture of 
a large artery or vein, is, of course, to be avoided, 
but it is altogether free of danger if fine needles 
are employed. 

Injection of a small area suflices whenever a 
simple incision in healthy tissue is alone required. 



32 REGIONAL ANESTHESIA. 

e.g., for the extraction of a foreign body from 
a definitely known situation. 

Regional anesthesia likewise permits of secur- 
ing insensibility of large fields of operation. 

Often infiltration of a single locality will des- 
troy sensation in most of the nerves leading to 
the field of operation. This is the case, e.g., in 
operations at the front of the neck, or for the 
cure of femoral or ino'uinal hernia. At other 




^ 3 5 

Fig. 17. — Pyramidal injections. (Pauchet.) Through the 
dermal wheals 1, 2, 3, and 4, one may painlessly infiltrate four 
triangular layers, union of which isolates a pyramid of anes- 
thetized tissue. (Removal of a shell fragment, etc.) 

times, one must infiltrate simultaneously all the 
layers surrounding the operative field. 

The technique wall be readily understood upon 
inspection of a few diagrams. 

Fig. 1 6 represents a pyramid. Its summit, 5, 
is deeply situated beneath the center of the opera- 
tive field, while its base, i, 2, 3, and 4, is at the 
cutaneous surface. Its lateral surfaces bound the 
field of operation; it is these sides which require 
to be injected. 

Dermal wheals, i, 2, 3, and 4, are first marked 
out. Through each of these a long needle is 



ARMAMENTARIUM. 



33 



introduced at. first toward point 5, then toward 
various points situated on the lateral surfaces, e.g., 
from I to 7, 4 to 7, 4 to 6, 3 to 6, 3 to 9, 2 to 
9, etc. The field of operation thus becomes de- 
sensitized without having been directly reached by 




Fig. 18. — Boat-shaped infiltration through dermal wheals 
1 and 2. Injection of four quadrilateral surfaces, permitting 
the removal of a tumor or foreign body. (Pauchet.) 



the anesthetic. Often two surface injections suf- 
fice to encompass the area perfectly. In other 
cases more than four are required, and the de- 
signs for injection assume, according to the ex- 
tent of the operative field, many varied forms: 
cone, base of a cone, a boat-shaped solid, etc. 
In Fig. 17 there are two points of entrance, viz., 



34 REGIONAL ANESTHESIA. 

I and 2, through which one injects toward 3, 4, 
5, 6, and 7, and finally infiltrates the subcutaneous 
tissue. Fig. 18 shows a field of operation on a 
limb; by the type of anesthesia depicted the bone 
may be desensitized. For all these injections a ^ 
per cent, solution is used. A more concentrated 
solution, from i per cent, to 4 per cent., injected 
in small amounts, is preferable wherever large 
quantities of liquid would lead to difficulty or dis- 
comfort, as in the orbit, eyelids, foreskin (circum- 
cision), fingers, etc. 

Small amounts of these concentrated solutions 
oftentimes exert a prolonged effect. Injection 
of a small quantity of anesthetic may affect not 
only the region injected but also the trunk of a 
nerve supplying surfaces at a distance. 

Perineural or Endoneural Injection by the Sub- 
cutaneous Route. — Anesthesia of a large nerve- 
trunk is often combined with peripheral infiltra- 
tion, and is governed by certain definite principles. 
In the first place, the point of the needle must 
be brought in contact with the nerve. This is 
readily done whenever the nerve is situated near a 
bone constituting a landmark, as in the case of 
the ulnar nerve, but is more difficult when such 
landmarks are absent and when the nerve is sit- 
uated in the midst of soft tissues. One of the 
most reliable indications of the needle reaching 
the nerve is afforded by a paresthesia radiating 
toward the periphery. The sharp pain referred 
in the direction of the nerve distribution demon- 
strates the contact of the needle with the nerve. 



ARMAMENTARIUM. 35 

The patient should therefore be told of this be- 
fore the needle is introduced and should let the 
operator know as soon as the paresthesia is ex- 
perienced. 

For the injection of large nerves it is well to 
use from i to 5 mils of a concentrated solution, 
2 to 4 per cent., of procaine-adrenin. 

The length of time one must wait after having 
made the injection depends upon the manner in 
which the nerve has been reached. If the needle 
has been introduced into the nerve root, as occurs 
in the case of the fifth nerve, abolition of sensa- 
tion is instantaneous. If the anesthetic has merely 
been injected around the nerve trunk, 5 to 20 
minutes elapse before complete insensibility is 
established. 

Direct Endoneural Injection. — Exposed nerve- 
trunks may be desensitized by the injection of a 
little 4 per cent, solution — viz., i ampoule — using 
a 3-centimeter needle. This procedure is very 
satisfactory for operations on nerves. The opera- 
tor begins by incising the layers of tissues cover- 
ing the nerve, as these have already been injected 
with procaine-adrenin. When the nerve has been 
located beneath the incision, he injects directly 
into the trunk the contents of a 2-mil ampoule 
of the 4 per cent, solution. 

Choice of Procedure. — The nature of the af- 
fection to be operated for — wound, removal of 
foreign body or of an inflammatory or neoplastic 
tumor — governs the form of the injection, and 
one must always be careful to desensitize a large 



36 REGIONAL ANESTHESIA. 

enough area in order to be prepared for all event- 
ualities and have a certain degree of latitude dur- 
ing the operation. One should avoid injecting 
the line of incision, and keep always at a certain 
distance from diseased tissues, particularly if in- 
fected. A well defined furuncle should be en- 
circled by an injection in the form of a pyramid, 
at quite a distance from the inflamed tissues. 
Diffuse phlegmons lend themselves to local anes- 
thesia only if it is possible to desensitize them at 
a distance from the field of operation. Malig- 
nancy of a tumor is no contraindication to regional 
anesthesia if the entire field can be desensitized 
without an injection in contact with the tumor. 
One must not forget the temporary ischemia 
which adrenin produces in the infiltrated area. 
This ischemia is often an advantage, as it reduces 
hemorrhage to the point of totally changing the 
aspect of certain operations, such as those for 
hemorrhoids, resection of the superior maxillary 
or of the tongue, laryngectomy, etc. But in plas- 
tic operations one must be careful not to ischemize 
the base of the flap to be turned back, as this 
would compromise its vitality. 

For plastic operations of the face, strong solu- 
tions of procaine without adrenin should be used; 
the solution runs out with the blood, and the anes- 
thesia need not last long, as these operations are 
always of short duration. 



CHAPTER III. 

CRANIAL OPERATIONS. 

The sensory nerves supplying the skin of the 
forehead, the temples, and the scalp, all pass at 
the level of a line encircling the skull from the 
eyelids to the external occipital protuberance (Fig. 
19). From there they branch to the summit of 




Fig. 19. — Nerve supply of the scalp. (Hirschfeld.) Injec- 
tion of a 1 per cent, solution of procaine-adrenin on a line 
completely surrounding the head above the ears and eyebrows 
completely desensitizes the nerve supply to the scalp. 



the cranium, where they spread out under the 
skin and the cranial aponeurosis. It is therefore 
very easy to anesthetize the entire cranium by a 
circular injection at this line. The nerves re- 

(37) 



38 



REGIONAL ANESTHESIA. 



ferred to supply not only the skin and pericranium, 
but also the bones of the summit of the cranium 
and their periosteum. The dura mater is not sen- 
sitive to pain except below the base of the skull; 
therefore operations upon the summit are painless. 




Fig. 20. — Tumor of the scalp. (Pauchef.) Whether the 
condition be a wen, a lipoma, or a sarcoma of the cranium, 
infiltration of the epicranium induces^ complete anesthesia. 
The illustration shows a lozenge-shaped injection circumscrib- 
ing the tumor through dermal wheals in accordance with the 
direction of the arrows. 



A simple circular injection under the skin suffices 
for trephining and operations on the brain. 

Where muscles, however, cover the cranial 
bones at the line of injection, they must be in- 
jected. A band of infiltration, starting in front 
from the eyelids, extending to the occiput, and 
passing above the arch of the ear, will desensi- 
tize the entire cranium above this line. It is not 



CRANIAL OPERATIONS. 



39 



necessary to make a subperiosteal injection. The 
band of anesthesia just mentioned possesses an- 
other advantage: The cranial arteries ascend, 
like the nerves, spreading out toward the summit 
under the epicranium or, as in the case of the 




Fig. 21. — Craniectomy for sarcoma. (Braun.) The frontal 
portion of the infiltration is designed to abolish sensibility of 
the anastomoses between the frontal and parietal nerves. 



temporal arteries, in the muscles. Adrenin con- 
tracts them, rendering the operative field relatively 
bloodless, and the various methods for arresting 
hemorrhage superfluous. At times the large ar- 
teries bleed a little and must be clamped; the 
small arteries do not bleed. For small fields of op- 
eration a j/2 per cent, solution suffices; for large 
fields, rich in vessels, a i per cent, will yield a 
better hemostasis. 



40 



REGIONAL ANESTHESIA. 



Starting from two wheals which correspond, re- 
spectively, to the extremities of the intended incision, 
one injects in a lozenge or quadrilateral form lo 
to 20 mils of a Yz per cent, solution (Figs. 20, 
21, 22), 




Fig. 22. — Anesthesia for trephining. (Pauchet.) Observe 
the crucial incision. A, the wound. B, dermal wheals. P, a 
zone of infiltration 1 centimeter in width surrounding the 
wound, as shown by the dotted line down to the bone. This 
yields perfect anesthesia and ischemia. 



Treatment of Large Wounds in the Soft 

Tissues, or of Compound Fractetres, 

OF THE Skull. 

Several wheals are made around the wound — 
as in Fig. 23, in which there are seven — suffi- 
ciently close together for the curvature of the skull 
to permit of the needle going under the epicran- 



CRANIAL OPERATIONS. 



41 



ium. With a i per cent, solution, a narrow band 
of infiltration, circumscribing the field of operation 
according to the line indicated, is now traced in 
the soft, subaponeurotic tissues. Along a distance 
of 5 centimeters, about 5 mils of solution should 
be injected. 



^^.^^^??§S=^5,^ 




Fig. 23. — Anesthesia of the epicranium around a wound 
{Paiicliet.) This can be practised in all operations upon the 
cranium for war wounds (bone and soft tissues) through as 
many dermal wheals as may be necessary to surround com- 
pletely the territory with a zone of infiltration, made with a 
1 per cent, solution. 



The peripheral line of injection should be far 
enough removed from the wound to permit of all 
necessary excision or enlargement for perfect re- 
pair, for any pedicle required or for a dissection 
necessary for plastic repair. Only a few moments 
are required for complete anesthesia. 

In their ambulance on the western fighting 
front, in September, 19 14, Pauchet and Labour e 



42 



REGIONAL ANESTHESIA. 



trephined a case for hemiplegia, under local anes- 
thesia, with the patient in the sitting position. 
After the completion of the operation the patient 
walked to the railway station, assisted by a fel- 
low-soldier. 



Removal of Malignant Tumors of the 
Cranium, with Bone Resection. 

The surgeon required to remove a tumor ad- 
herent to the skull should at the same time re- 
move the skin covering the tumor and a rather 




Fig. 24. — Repair of a craniectomy. {Braun.) Shows a 
flap to be re-applied as covering to the bony surface excised. 
It is well to cover the opening over the brain with a layer of 
fascia lata to replace the dura mater and prevent adhesions of 
the skin to the deeper surfaces. Skin grafts may be used to 
cover the denuded occipital zone when new tissue has grown 
over the skull. The opening in the skull should be reinforced 
with a chondrocostal piece or a gold plate. All this may be 
perfectly done under local anesthesia. 



CRANIAL OPERATIONS. 43 

large section of bone. The operation will be pain- 
less, since the dura mater, together with all the 
other local tissues, are insensitive. The anesthesia 
should .be instituted as already indicated, viz., on 
a line extending from the eyes to the occipital 
protuberance, the line of the hat band. 

Equally good results are obtained in the case 
of a sarcoma originating in the periosteum and 
adhering to the skin. The surgeon is enabled to 
remove painlessly the skin, pericranium, perios- 
teum, bone tissues, and dura mater. The brain 
surface should under these conditions be recovered 
with skin. The liberation of an area of skin pos- 
teriorly for this purpose may likewise be effected 
without pain. 

Trephining the Temporal Region. 

Regional anesthesia permits of removal of 
epidural hematomas of the inferior meninges, 
craniectomy for decompression (Babinski), and re- 
moval of bone fragments and foreign bodies. The 
dura mater near the base of the cranium is sen- 
sitive, but only moderately so. 

Fig. 25 shows how to place the wheals, and 
the form of the injection, for the dissection of a 
temporal osteocutaneous flap. 

One is in the middle of the superior border 
of the zygoma; at this point one injects subcuta- 
neously a ^ or i per cent, solution. There is 
also to be infiltrated a layer of temporal muscle 
as shown in the diagrammatic Fig. 26, represent- 



44 



REGIONAL ANESTHESIA. 




Fig. 25. — Trephining the temporal region for decompression, 
(Pauchet.) The horse-shoe-shaped flap comprises the skin, 
the temporal muscle, and the periosteum. The illustration 
shows the surrounding band of anesthesia induced through six 
dermal wheals. The lower side of the pentagon, wheals 1, 2, 
and 6, should be infiltrated down to the bone with a 1 per 
cent, solution of procaine-adrenin ; the other sides, with a ^ 
per cent, solution. 




y//mm^^^^/^^///////j?/mw^ 



Z/ 






inmiiiMhimmmirim miiiiiiiiiini/inmimmii 



Fig. 26. — Anesthesia of the base of the pentagon (Fig. 25) 
for trephining the temporal region. (Pauchet.) The fan- 
shaped infiltration follows the direction of the arrows. Ar- 
rows 1 and 2 pierce the temporal muscle and reach the bone; 
arrow 3 infiltrates the subcutaneous tissue. 



CRANIAL OPERATIONS. 



45 



a horizontal incision parallel to the superior 



border of the zygoma 



through 



the skin, temporal 




Fig. 27. — Photograph of a craniectomy made in the service 
of Dr. Babinski. (PaucJiet.) The musculo-cutaneous flap is 
held by two clamps ; note that the operation is practically 
bloodless on account of the adrenin contained in the solution 
injected. The dura mater is not opened. 



muscle and temporal bone. The needle is first 
introduced through wheal i, perpendicularly 
from the surface down to the bone (arrow i) 



46 REGIONAL ANESTHESIA. 

then obliquely toward the anterior and posterior 
margins of the temporal muscle, again down to 
the bone (arrow 2) and following a horizontal 
plane, and finally even more obliquely in the sub- 
cutaneous tissue (arrow 3), from 2 to 6. To in- 
filtrate this layer, about 30 mils is required; to 
circumscribe the field of operation, about 30 mils 
more; in all, about 60 mils of procaine-adrenin 
solution. 

Removal of the Gasserian ganglion would be 
practicable by this method, but at the present time 
injection of the branches of the 5th nerve at their 
emergence from the ganglion, and their destruc- 
tion by alcohol, is preferred. 

Exposure of the Cerebellum. 

In 19 1 2 we suggested to Thierry de Martel 
the following technique, which this skillful opera- 
tor was the first to apply in tumor of the cere- 
bellum with complete success. Fig. 28 shows the 
situation of the wheals and the shape of the in- 
cision for exposing the cerebellar hemispheres. It 
is best not to depart from this tracing, even if 
one has decided not to touch more than half of 
the cerebellum. Points 3 and 9 are placed just 
behind the base of the mastoid. From these two 
points, as from i, 2, and 10, the necessary injec- 
tions are made in the muscles of the neck. Next, 
the muscular layer outlined by the points of in- 
jection is impregnated with a solution of procaine- 
adrenin along the line shown. In the flap itself 



CRANIAL OPERATIONS. 



47 



no injection is made. This illustration, taken in 
conjunction with that for temporal injection (Fig. 
26), defines the path of the needle. The point 
should penetrate to the transverse processes of the 
cervical vertebrae and down to the occiput. Union 
of the successive injections bv subcutaneous injec- 




Fig. 28. — Trephining for a tumor of the cerebellum. 
(Pauchet.) The 10 dermal wheals in the form of a trapezium 
surround the field of operation with a zone of infiltration. 
The proposed flap is shown by the dark line in the shape of 
a horse-shoe. 



tions follows; lOO to 120 mils of solution are 
used, over half of which goes into the muscles of 
the neck. Thierry de Martel operated with his 
patient sitting astride a chair, with the arms rest- 
ing on its back, and his head resting on his arms. 
The dura mater of the posterior cerebral fossae 
and the cerebellum are insensitive to pain. 



CHAPTER IV. 
ANESTHESIA OE THE HEAD AND NECK. 

The surgery of the head and the neck is of 
interest both to general operators and, particu- 
larly, to three classes of specialists, the ophthal- 
mologist, the otorhinolaryngologist, and the stom- 
atologist. 

In these regions the sensory supply is fur- 
nished by the fifth nerve and the cervical plexus. 
The fifth nerve is predominant in the face. As 
several branches often combine in supplying sen- 
sation to a single region, it is sometimes neces- 
sary in these tissues to combine root or trunk 
anesthesia with peripheral infiltration. Or, it may 
be necessary to combine root anesthesia with anes- 
thesia of the neighboring regions. 

We shall first consider synthetically the subject 
of anesthesia of the nerve roots and nerve branches, 
and then describe the technique for each operation 
involved in the three specialties mentioned. 



Anesthesia of the Gasserian Ganglion. 

The ganglion of the fifth nerve is intracranial. 
It rests upon the summit of the petrous portion 
of the temporal bone (Fig. 29) in a fold of the 
dura mater just above and behind the foramen 
ovale, and in the immediate neighborhood of a 
(48) 



ANESTHESIA OF THE HEAD AND NECK. 49 

venous sinus and of the motor nerves of the eye 
(fourth and sixth). It has three branches: the 
ophthahiiic, the superior maxillary, and the in- 
ferior maxillary. The ganglion is accessible through 
the foramen ovale, an orifice measuring J4 centi- 
meter by 2 or 3 millimeters. This foramen is 
situated on the floor of the cranium immediatelv 




Fig. 29. — The ganglion of Gasser. (Hirschfeld.) It rests 
upon the summit of the petrous portion of the temporal bone. 
From above downward the illustration shows the origin of 
the ophthalmic nerve and of the superior and inferior maxil- 
lary nerves. 



behind the base of the pterygoid process. It cor- 
responds, for the superior maxillary, to the outer 
side of the last two molars in the sagittal region. 
It is located at a depth of 45 millimeters from 
the zygoma. 

Indications for Gasserian anesthesia are two in 
number : 

A. Surgical operations on the face. 

4 



50 



REGIONAL ANESTHESIA. 



B, Alcoholization of the nerve to combat per- 
sistent neuralgia (Sicard). 

The anesthetist should bear in mind the fol- 
lowing precepts : 




Fig. 30. — Injection of the Gasserian ganglion through the 
foramen ovale. (Braun.) (1) The needle represented by the 
dotted lines is introduced 3 centimeters from the commissure 
of the lips, in the direction of the zj^gomatic arch, until it 
reaches the subtemporal region between the two maxillary 
bones. (2) The black line needle shows the shank raised and 
the needle directed toward the z3^gomatic tubercle. Being kept 
in contact with the bone, it reaches the foramen ovale, com- 
ing in contact with the fifth nerve, in the terminal branches 
of which it provokes pain. 



(i) Use a fine, sharp, flexible, but strong 
needle. 

(2) Inject slowly. 

(3) Employ a concentrated solution 
quantities, viz., i to 2 mils of a 2 or ^ 
solution of procaine-adrenin. 



in small 
4 per cent. 



ANESTHESL\ OF THE HEAD AND NECK. 



51 



In spite of these precautions, vertigo, vomiting 
and even symptoms of meningitis are sometimes 
observed. These post-anesthetic disturbances do 




Fig. 31. — Injection of the Gasserian ganglion (Braiin.) 
The patient should sit erect, looking directly forward. The 
surgeon introduces the needle through the cheek 3 centimeters 
from the labial commissure, so directing it that it remains in 
the plane of the subject's pupil. The index finger of the left 
hand is introduced into the patient's mouth to make certain 
that the needle shall not pierce the mucous membrane. The 
needle should be directed between the inferior maxillary and 
the tuberosity of the superior maxillary. 



not detract from the value of the procedure be- 
cause the method of anesthesia under discussion is 
employed for serious operations on the face, or 
obstinate neuralgia of the fifth nerve, which war- 
rant its application. 



52 



REGIONAL ANESTHESIA. 



Technique of the Injection. — The patient may 
be in the lying or sitting position. Injection is 
easier on a sitting subject, the operator standing 
or sitting in front of the patient. A needle 9 
centimeters in length shotild be selected. 

The landmarks include some that are appre- 




Fig. 32. — Injection of the Gasserian ganglion. (Brann). 
The same maneuver as in the preceding illustration. The needle 
is first directed at the middle of the zygomatic arch. As soon 
as the point touches the bone of the subtemporal region, the 
shank is raised so that the point is directed at the zygomatic 
tubercle. Being then pushed forv\^ard about 1 centimeter, it 
will penetrate the foramen ovale. 



ciable to sight or palpation and others which are 
found by the point of the needle as it is introduced, 
(i) When the subject looks straight to the 
front the pupil of the eye supplies the direction 
of the frontal plane in which the needle must be 
directed. 

(2) The labial fissure. 

(3) The second upper molar. 



ANESTHESIA OF THE HEAD AND NECK. 



53 



(4) The ascending ramus of the inferior 
maxillary, the inner surface of which may be felt 
by introducing the index finger into the mouth. 

(5) The tuberosity of the superior maxillary. 

(6) The bone in the subtemporal region; the 
needle, when correctly directed, will strike against 




Fig. 33. — The sensory nerve supply of the face and neck. 
(Hirschfeld.) (1) Ophthalmic. (2) Superior maxillary. (3) 
Inferior maxillary. (4) Cervical plexus (anterior branches). 



this resistant surface, which is situated in front 
of the foramen ovale. 

(7) The middle of the zygomatic arch and the 
tubercle of the zygoma; the tubercle indicates the 
point at which the needle must be directed in 
order to enter the foramen; the middle of the 
arch indicates the bony region anterior to the 
foramen against which the needle must strike be- 
fore penetrating the foramen (Figs. 30, 31, 32). 



54 



REGIONAL ANESTHESIA. 



The cheek is pierced 3 centimeters beyond the 
labial fissure, on a line with the lobe of the ear. 
The needle is inserted with one hand. With the 
index finger of the other in the mouth, the second 




Fig. 34. — Removal of a cancer from the velum palati and 
left tonsil by transverse incision of the cheek and resection of 
the ascending ramus of the inferior maxillary bone after 
anesthesia of the Gasserian ganglion. (Pauchet.) The 
photograph shows the loosening of the upper fragment of the 
inferior maxillary, operated upon by Pauchet and Sourdat. 



superior molar and the tuberosity of the superior 
maxillary are located within, and the ascending 
ramus of the mandible without. The needle is 



ANESTHESIA OF THE HEAD AND NECK. 



55 



to pass in the interval bounded by these bones; 
the finger in the mouth follows the needle point 
under the mucous membrane and prevents it from 
perforating the latter. 




Fig, 35. — The wound is held open after the resection of the 
maxillary has been completed. (Pauchet.) 



One next aims at the subtemporal region to 
strike the bony surface already mentioned. The 
needle should be directed somewhat obliquely in- 
ward, i.e., in the line of the pupil when the sub- 
ject is looking straight ahead. It should be also 
slightly oblique upward, i.e., should virtually pass 
through the middle of the zygoma, — which can be 



56 



REGIONAL ANESTHESIA. 



controlled by surveying the patient in profile. Its 
point should be behind the second upper molar. 
Thus directed, the needle enters the subtemporal 
region, which marks the end of the first stage of 




Fig. 36. — The tonsillar space is tamponed after the resec- 
tion of a part of the pharynx and of the tongue. The borders 
of the incised cheek are retracted, showing the extent of the 
wound. The tongue is drawn out with the aid of a cord held 
by the assistant. 



the injection. Care should be taken to do all this 
very slowly, in order not to blunt the point of 
the needle by contact with the bone. 

Then the point is disengaged and, slightly 
raising the shank but still remaining in the plane 
of the pupil, the point is advanced about i centi- 



ANESTHESIA OF THE HEAD AND NECK. 57 

meter, gliding along the surface of the subtem- 
poral bone. In profile one aims this time for 
the tubercle of the zygoma. Resistance ceases as 
the needle enters the foramen ovale. A tense 
membrane is traversed about 7 centimeters be- 
neath the skin. When the patient notices radiat- 
ing pains at first in the superior maxillary nerA^e, 
entrance into the ganglion is indicated. One 
should then inject i to ij^ mils of a 2 per cent, 
procaine-adrenin, very slowly and gently pushing 
the needle in another J^ centimeter. 

By the same route, but without entering the 
foramen ovale, one may reach the inferior maxil- 
lary nerve as it emerges from this foramen and 
limit the injection to it. It is difficult clearly to 
describe this procedure in words, and we have 
therefore attempted to supplement the explanation 
and more fully guide the operator by the several 
appended cuts. 



Anesthesia of the Ophthalmic Nerve. 

The frontal, internal and external nasal, and 
lachrymal nerves separate from the origin of the 
ophthalmic immediately before it enters the orbit. 
The ophthalmic is fan-shaped and is situated be- 
tween the bony plate and the muscular cone of 
the orbit; the injection must, therefore, be made 
between these two. The frontal and lachrymal 
nerves are situated externally and emerge through 
the superior orbital fissure. They are reached 
along the external wall of the orbit. 



58 



REGIONAL ANESTHESIA. 




Fig. Zl . — The ophthalmic nerve and its branches. (Testut.) 
(1) Ophthalmic. (2) Nasal. (3) Lachrymal. (4) Frontal. 
(5) External nasal. (6) Internal frontal. (7) Ethmoidal. 




Fig. 38. — Base of the orbit. (Testut.) Zinn's ring, where 
the motor muscles of the eye are attached. On the left is 
seen the sphenoidal fissure in the center of Zinn's ring. The 
nasal nerve and ophthalmic vein are in the ring. The frontal, 
lachrymal, and pathetic nerves are in the sphenoidal fissure. 



ANESTHESIA OF THE HEAD AND NECK. 59 

The nasal nerves occupy the upper internal 
angle of the orbit, and are infiltrated at that 
point. 

The frontal nerves supply sensation to a tri- 
angular area of integument with its base cor- 
responding to the entire frontal region above the 




Fig. 39. — Supraorbital branches of the ophthalmic nerve. 
(Hirschfeld.) To anesthetize these branches, inject parallel 
to the superior border of the orbit. 



root of the nose and its apex at the scalp (Fig. 
40). They also sensitize the frontal sinuses and 
the upper eyelids. The nasal nerves supply the 
frontal, ethmoidal, and sphenoidal sinuses, the 
nasal septum, and the nasal lobes. 

Injections may be made from three points, ac- 
cording to the operation required. 



60 



REGIONAL ANESTHESIA. 



(a) Frontal Infiltration. — The operator injects 
under the skin lo mils of a i per cent, procaine- 
adrenin, commencing above the external orbital 
apophysis and ending above the corresponding 
apophysis on the opposite side. The line of in- 
jection is shown by the black line in Fig. 40. 




Fig. 40. — Injections along the black line anesthetize the 
ophthalmic branches of the fifth nerve and render insensible 
a triangular area. (Pauchet and Sourdat.) 



(b) External Orbital Infiltration. — This blocks 
the frontal and lachrymal nerves. 

The needle is introduced at the external angle 
and the outer wall of the orbit followed with its 
point. At a depth of about 4>4 centimeters the 
needle point will come in contact with bone, the 



ANESTHESIA OF THE HEAD AND NECK. 



61 



orbital vault, and will have passed into the exter- 
nal portion of the sphenoidal fissure, where are sit- 
uated the frontal and lachrymal nerves. Five mils 
of the 2 per cent, solution are now injected, and 
the resulting anesthesia will be complete (Figs. 
41, 42). 




Fig. 41. — Intraorbital injections for infiltration of the 
ophthalmic branches. (Braun.) To the left, an external in- 
jection, which keeps in contact with the external orbital wall. 
At a depth of 4 centimeters the needle point strikes the orbital 
vault. It now crosses the extremity of the sphenoidal fissure, 
along which pass the lachrymal and nasal nerves. A 1 per 
cent, solution of procaine-adrenin is injected. 

To the right, an internal injection. The needle follows 
the superointernal angle of the orbit, constantly in contact with 
the bone and grazing the ethmoidal foramen. At a depth of 4 
centimeters it comes in contact with the orbital vault. The 
solution is injected while the needle is being introduced. 



(c) Internal Orbital Infiltration. — At an equal 
distance from the eyebrow and the caruncle, i.e., 
I centimeter above the internal commissure of the 
eyelids, the needle is introduced against the supe- 
rior internal angle of the bony wall, which should 



62 



REGIONAL ANESTHESIA. 



be continuously followed. At a depth of 4 or at 
most 4^ centimeters, 5 mils of a 2 per cent, solu- 
tion are injected (Figs. 41, 42). 

This last injection anesthetizes the nasal wall 
and the ethmoidal, sphenoidal, and frontal sinuses, 
as well as the lobe of the nose. It induces 




Fig. 42. — Anesthesia of the ophthalmic branches by the 
orbital route : (1) External. (2) Internal. (Pauchet.) The 
dotted line shows the shape and extent of the orbital orifice. 
Needle 1 is entered at the extreme angle of the commis- 
sure of the eyelids. It follows the bony wall and stops only 
when it comes in contact with the orbital vault, where it crosses 
the sphenoidal fissure (see Fig. 41). Needle 2 is entered at 
the superior internal border of the orbit, one finger breadth 
above the caruncle. The point is kept in constant contact with 
'the superior internal angle of the bony wall to reach the 
ethmoid nerves. 



edema of the upper lid, causes projection of the 
eye-ball, and sometimes results in blindness for a 
few minutes. The optic nerve is not anesthetized. 



ANESTHESIA OF THE HEAD AND NECK. 



63 



Anesthesia of tfie Superior Maxillary Nerve. 

The superior maxillary passes through the 
foramen rotundum at the bottom of the pterygo- 
maxillary fissure, precisely between the tuberosity 




Fig. 43. — Injection of the superior maxillary at the fora- 
men rotundum by the external route. (Braun.) The needle is 
introduced at the intersection of a vertical line drawn down- 
ward following the external border of the orbit and a line 
drawn along the inferior border of the superior maxillary bone 
(dotted lines). 



of the superior maxillary and the base of the 
pterygoid process. 

(a) External Route (Figs. 43, 44). — Locate 
the zygomatic arch with the finger; mark its 
lower border with ink; mark the external border 
of the orbit in the same manner at the point 
where a vertical line drawn from this external 



64 



REGIONAL ANESTHESIA. 



border meets the zygomatic arch (just behind the 
lower angle of the body of the malar bone), and 
introduce the needle to a depth of 5 to 6 centi- 
meters. In this way the nerve is reached at once; 
but it is preferable to attain first, with the pomt 
of the needle, the body of the maxillary on its 
inclined surface, feeling one's way, and directing 
the needle deeply. Suddenly the needle will come 




Fig, 44. — The needle is first directed toward the tuberosity 
of the maxillary bone, whence it penetrates directly about 4 
centimeters and enters the pterygo-maxillary fissure. (Braun.) 
When the patient complains of a shooting pain in the teeth, 
from 3 to 4 mils of a 2 per cent, anesthetic solution are injected. 



to an empty space and touch the nerve, when the 
patient will experience a sharp pain in the face 
and upper teeth. Five mils of a 2 per cent, pro- 
caine-adrenin solution are now injected, and while 
withdrawing the needle, 5 mils of a ^ per cent, 
solution. To cause the branches of the internal 
maxillary to contract, it is often necessary to have 
the patient open his mouth, when the needle will 
enter more easily (Fig. 45). 



ANESTHESIA OF THE HEAD AND NECK. 



65 




Fig. 45. — Anesthesia of the superior and inferior maxillary 
through the same orifice. (Pauchet.) The patient is made to 
open his mouth. The needle is introduced below the zygo- 
matic arch and introduced as far as the pterygoid process, then 
partly withdrawn and the point directed slightly forward to 
reach the pterygo-maxillary fissure, where it encounters the 
superior maxillary nerve at the foramen rotundum. Again the 
needle is partly withdrawn and then reinserted about 1 centi- 
meter further back, where it reaches the foramen ovale be- 
hind the root of the pterygoid process. The foramen ovale 
is at a depth of about 4 to 5 centimeters. 



66 REGIONAL ANESTHESIA. 

(b) Orbital Route (Figs. 46, 47).— At the 
junction of the external, lateral, and inferior bor- 
ders of the orbit, a dermal wheal is made and the 




Fig. 46. — Anesthesia of the left superior maxillary nerve 
at the foramen rotundum by the orbital route. (Braun.) The 
needle, which at first is held vertically (Fig. 47), comes in 
contact with the floor of the orbit on a level with its in- 
ferior external angle. Entering deeper, it reaches a space on 
a level with the orbital fissure. Thence it progresses back- 
ward almost horizontally, following the direction of the fis- 
sure. At a depth of about 5 centimeters it reaches the base 
of the cranium and the foramen rotundum. One to 2 mils of 
a 2 per cent, anesthetic solution are injected. 



point of the needle then introduced almost ver- 
tically downward. In order that it shall pass 
along the floor of the orbit, it should be directed 



ANESTHESIA OF THE HEAD AND NECK. 



67 



slightly backward. At a depth of about i centi- 
meter it will traverse a fibrous layer — the fissure 
of the orbital floor. As soon as the needle reaches 
this space its flange end should be lowered so as 
to bring it almost horizontal, while the head of 




Fig. 47. — This figure shows the manner in which the needle 
point is made to follow the floor of the orbit. By placing a 
rubber shield upon the needle, the surgeon can make the lat- 
ter serve as an index of depth in the procedure described in 
Fig. 46. (Braun.) 



the patient is held quite erect. If the needle is not 
horizontal, it will enter the subtemporal space. 
Yet it should not be introduced too high up, or 
it wall enter the eyeball. It should be directed in 
the plane of the fissure, i.e., in the direction of 
the inferior, external angle. One should always 



68 



REGIONAL ANESTHESIA. 



feel a certain resistance at this point. At a depth 
of 5 centimeters, the situation of the needle will 
correspond to the foramen rotundum. At this 
point it will come in contact with the base of the 
skull. Five mils of a 2 per cent, solution of neo- 




Fig. 48. — Emergence of the infraorbital nerve. (Hirsch- 
feld.) On the same vertical line as the supraorbital nerve, it 
is situated J-^ centimeter below the middle of the lower border 
of the orbital foramen. 



caine-adrenin are now injected. At times a tem- 
porary paralysis of the muscles of the eye, or a 
hematoma in the pterygomaxillary fissure, will ap- 
pear. Both these conditions are incidents devoid 
of serious consequences. 



ANESTHESIA OF THE HEAD AND NECK. 69 

Anesthesia of the Infraorbital Nerve. 

The infraorbital nerve, a branch of the supe- 
rior maxillary, is accessible through the cheek. 
The lower border of the orbit is marked with a 
dermal pencil, a line drawn from the center down- 
ward Yz centimeter, and a cross made. This 
corresponds to the point of emergence of the in- 
fraorbital nerve. The three apertures whence the 
infraorbital and mental nerves arise are on the 
same vertical line, and correspond to the interval 
between the first and second premolars (Fig. 45). 
A dermal wheal is made, and the subcutaneous 
cellular tissues infiltrated so that contact will not 
be painful. Then, with the needle, the infraorbital 
opening is found. Coming in contact with the 
bone, the operator feels around while directing the 
needle a little higher and outward; soon he be- 
comes aware of a small depression and penetrates 
into a canal. The patient feels a sharp pain. 
One mil of a 2 per cent, solution is now injected. 
The anesthesia thus induced extends to the lower 
lid, the upper lip, the nasal ala, a part of the 
skin and mucous membrane of the cheek, the mu- 
cous membrane of the lips, the margins of the 
superior alveolar process, as well as the inferior 
walls of the superior maxillary and the incisor 
and canine teeth. 



70 REGIONAL ANESTHESIA. 

Anesthesia of the Superior Dental 
Nerves. 

(a) Buccal Route. — The zygomatic arch is 
located through the mouth. When its most ante- 
rior point is feU, the mucous membrane is pierced 
and the needle introduced for a distance of i or 
2 centimeters. The patient will usually feel pain 
in his teeth. Five mils of a 2 per cent, procaine- 
adrenin solution are now injected. 

(b) External Route. — The zygomatic arch is 
located and the same route followed as that taken 
to reach the superior maxillary nerve. As soon 
as the tuberosity of the superior maxillary is at- 
tained, 5 mils of solution are injected. This in- 
jection anesthetizes the upper molars and pre- 
molars as well as the mucous membrane of the 
maxillary sinus (Fig. 29). 

Anesthesia of the Nerves of the Palate. 

The inferior palatine nerve emerges from the 
posterior palatine canal above the last molar. The 
nasopalatine nerve arises in the anterior palatine 
canal, in the median line and behind the incisors. 
The needle is introduced anteriorly, under the 
mucous membrane of the palate, immediately be- 
hind the teeth and in the median line. One mil 
of a 2 per cent, procaine-adrenin solution is in- 
jected. Then, behind the palate, i to ij4 centi- 
meters within the second molar, or rather, within 
the border of the gums, 2 mils of the solution 
are introduced. This type of anesthesia, carried 



ANESTHESIA OF THE HEAD AND NECK. 



71 




Fig. 49. — To the right are shown the three palatine nerves 
descending toward the posterior palatine foramen. To the 
left, at the base of the nose, is the ethmoidal branch of the 
internal nasal nerve. 




Fig. 50. — Anesthesia of the hard palate. (Pauchet.) In 
front is the nasopalatine nerve, ^ centimeter behind the 
middle incisors. The surgeon injects 1 mil of a 2 per cent, 
solution directly under the mucous membrane. Behind, the 
nerves emerging from the posterior foramen tO' the right and 
left, 1 centimeter within and above the last molar, 1 mil of 
the strong solution is injected beneath the mucous membrane. 



72 REGIONAL ANESTHESIA. 

out also on the opposite side, permits the surgeon, 
with the three points of infiltration, to operate on 
the mucous membrane of the hard palate and 
periosteum, though not on the teeth. 

Anesthesia of the Buccal Nerve. 

This nerve rests upon the tuberosity of the 
superior maxillary and is distributed over the mu- 
cous membrane of the cheek. It is accessible, like 
the superior dental nerve, by an injection passing 
along the tuberosity and following a vertical line 
running from the last upper molar to the last 
lower molar. 



Anesthesia of the Inferior AIaxillary 
Nerve. 

As already pointed out, the trunk of the in- 
ferior maxillary nerve is accessible, at its emerg- 
ence from the foramen ovale, by the same route 
and with the same procedure as was described 
for infiltration of the Gasserian ganglion. To 
limit the injection to this trunk, it is sufficient to 
make the injection upon arriving at but not enter- 
ing the foramen ovale. The advance of the needle 
should be arrested as soon as the resistance of 
the bone ceases, indicating that the anterior bor- 
der of the aperture has been passed. 

The following mode of procedure reaches the 
nerve without risk of penetrating too far, and 
the operator should be as familiar with it as with 



ANESTHESIA OF THE HEAD AND NECK. 73 

the method first described, as certain conditions 
may render it preferable, e.g., anatomical deformi- 
ties, tumors, etc. 

The lower border of the zygomatic arch is 
traced on the skin, its exact center found, and 




Fig. 51. — Anesthesia of the inferior maxillary nerve. 
(Braun.) The operator places a small fragment of cork upon 
the needle, as an index. The needle is introduced just below 
the center of the zygomatic arch. At a depth of 4 centimeters 
the point touches the pterygoid process. With the needle held 
firmly in position, the cork is slid down to a level with the 
skin. The needle is then partly withdrawn and reintroduced 
at an angle, so as to touch a point 1 centimeter behind the 
point first reached. When the index cork touches the skin, the 
point of the needle is near the foramen ovale and when it 
comes in contact with the nerve the patient feels a sharp pain 
in the lower jaw. Two mils of a 2 per cent, solution of pro- 
caine-adrenin are then injected. 

a dermal wheal made at this point. A needle 
6 centimeters long is now introduced transversely 
to a depth of 4 to 5 centimeters so that its point 
will strike against the pterygoid process, which is 
I centimeter from the foramen ovale. As a guide 
a thread or small piece of rubber, passed over the 



74 REGIONAL ANESTHESIA. 

needle before its introduction, is now fastened pre- 
cisely at a level with the skin. The needle is then 
drawn toward the operator, though not withdrawn 
altogether, and re-inserted to the depth marked on 
the needle, aiming, however, about i centimeter 
behind the bony obstruction (pterygoid). The 
earlier and later directions of the needle should 




Fig. 52. — Direct injection of the inferior maxillary at the 
foramen ovale. (Braun.) The needle is introduced at the 
junction of the middle and posterior thirds of the zygomatic 
arch and directed inward about 5 centimeters, when it will 
reach the foramen ovale. If it strikes bone, the latter is the 
pterygoid process ; it should then be withdrawn a few centi- 
meters and reintroduced further back. The foramen ovale is 
located immediately behind the pterygoid process. 

form between them an angle of 30°. As soon as 
the needle has reached the same depth, though 
somewhat posteriorly, it is pushed a few milli- 
meters further in, and the patient will feel a 
sharp pain in the tongue or the inferior maxillary. 
This indicates that the needle is in the body of 
the nerve (Figs. 51, 52). Five mils of a 2 per 
cent, procaine-adrenin solution are now injected. 
(See also Offerhaus's procedure, p. 98.) 



ANESTHESIA OF THE HEAD AND NECK. 



75 



Anesthesia of the Inferior Dental 
Nerve 

This is a large terminal branch of the inferior 
maxillary. It diverges at an acute angle from 
the lingual nerve and passes between the internal 




Fig. 53. — Injection of the inferior dental nerve at the in- 
ferior dental foramen. (Braun.) The arrow indicates the 
point at which the nerve should be injected. The dotted ar- 
row shows the retromolar trigone. The needle should be first 
directed to this trigone 1 centimeter above the molar, then 
should follow the inner wall of the maxillary bone until its 
point reaches the nerve. One to 2 mils of a 2 per cent, solu- 
tion are then injected. 



pterygoid muscle and the ascending ramus of the 
inferior maxillary bone until, arriving at the pos- 
terior orifice of the dental canal, it emerges on a 
level with the chin through the mental foramen. 

Upon examination of an inferior maxillary 
bone, there will be found immediately behind the 



7^ 



REGIONAL ANESTHESIA. 



last molar a triangular bony surface, limited ex- 
ternally by a prolongation of the coronoid process 
and within by a ridge of bone which, likewise de- 
tached from the process, passes down toward the 
inner side of the alveolus of the third molar. 




Fig. 54. — Shows the movements imparted to the needle to 
reach the inferior dental foramen. (Pauchet.) The Ungual 
nerve may be reached in the same way. 



This small triangle which is normally covered with 
mucous membrane, serves as the principal land- 
mark in the introduction of the needle. 

The patient is seated in front of the operator, 
with his mouth wide open. The index finger is 
passed into the mouth, the anterior border of the 
coronoid found, and within this border the retro- 



ANESTHESIA OF THE HEAD AND NECK. 



77 



molar trigone (Braun) located. A needle 9 centi- 
meters long is taken in the right hand, and being 
kept I centimeter from the inferior canine on the 




Fig. 55. — First position of the needle in going for the retro- 
molar trigone. (Pauchet.) The needle should at first be kept 
in contact with the canine tooth of the opposite side until the 
trigone is reached. The handle of the syringe is then swung 
to the opp'osite side, so the needle is on a line with the teeth, 
and pushed along the border of the bone to the foramen. 



grinding surface 



opposite side, on a level with the 
of the teeth, directed toward the trigone, i.e., the 
intra-buccal fold of the coronoid. The point of 
the needle penetrates the mucous membrane i 
centimeter above and outside of the last molar. 



78 



REGIONAL ANESTHESIA. 



As soon as the membrane has been punctured the 
point strikes against bone; if not, the point is too 
far within. Then the operator, feehng his way, 
inserts the point of the needle until it reaches the 
ridge of the bone (Fig. 54). It should slide 




Fig. 56. — Anesthesia of the inferior dental and lingual 
nerves on the right side. (Pauchet.) (1) Right inferior den- 
tal nerve. (2) Right lingual nerve. (3) Left inferior canine. 
The needle is directed from the left lower canine toward the 
anterior border of the ascending ramus of the right inferior 
maxillary (Position 1). It is then directed to the internal 
surface and introduced to a depth of about 2 centimeters 
(Position II). 



along the inner surface of the inferior maxillary; 
then, without losing its contact with the bone, 
penetrate 2 to 2j4 more centimeters, at which 
point the operator injects 5 mils of a i per cent, 
solution (Figs. 53, 55, and 56). 



ANESTHESIA OF THE HEAD AND NECK. 79 



Anesthesia of the Mental Nerve. 

On a vertical line passing at the same time 
the supra- and infra- orbital nerves and corre- 
sponding to the space between the two first lower 
molars, is to be found the mental foramen of the 
inferior maxillary. This is situated at equal dis- 
tances from the superior and inferior borders of 
the jaw, and below the interval between the first 
and second molars. After passing through the 
soft tissues to this point, the surgeon injects a 2 
per cent, solution of procaine-adrenin. 



Anesthesia of the Lingual Nerve. 

This leaves the inferior dental nerve and branches 
off to the tongue, describing a curve with an 
antero-superior concavity. It should be borne in 
mind that this nerve is in the lower part of the 
tongue, situated very superficially beneath the mu- 
cous membrane. 

The procedure is therefore, as follows: The 
tongue is held in a compress and brought for- 
ward toward the opposite corner of the mouth. 
A line of anesthesia 4 centimeters long is made in 
the groove formed by the tongue and gums, with 
a I or 2 per cent, solution of procaine-adrenin. 

This nerve may also be infiltrated by proceed- 
ing as for the inferior dental. 



80- REGIONAL ANESTHESIA. 

Remarks. 

It would seem, at first sight, that in facial op- 
erations, anesthesia of the Gasserian ganglion 
should prove all sufiicient. Actually this is not 
the case. In the first place, the severity of the 
Gasserian procedure justifies its employment only 
in serious interventions, as already pointed out. 
It is preferable, therefore, to anesthetize the peri- 
pheral trunks. Again, there exist anastomoses 
with the cranial nerves or with branches of the 
cervical plexus, which would render the anesthesia 
incomplete were it confined to a single nerve 
trunk. 

Indications for subcutaneous peripheral infiltra- 
tion, or for the spraying or application of cocaine 
to the mucous membranes, therefore, frequently 
exist. These various procedures, trunk anesthesia, 
local infiltration, and local application, are of mu- 
tual assistance and it is a combination of the 
three which produces a practically complete anes- 
thesia. 

REGIONAL ANESTHESIA IN RHINOLOGY. 

Submucous Resection of the Cartilage 
OF THE Nasal Septum. 

Tampons of a strong solution of adrenin-co- 
caine are applied for lo minutes. A 2 per cent, 
solution of procaine-adrenin is injected under the 
mucous membrane of the septum, both on its con- 
vex and its concave surfaces. One should in- 
filtrate also, especially if the deviation is exten- 



ANESTHESIA OF THE HEAD AXD NECK. 



81 



sive, the three nerve trunks which together sensi- 
tize the septum, above and forward, below and 
forward, in the floor and behind. 

Hypertrophy of the Lower and IMiddle 
Turbinates. 

Resection of the Upper and Lozver Turbinates 
and of Xasal Myxomas. — Tampons of cocaine 
which contract the mucous membrane usually suf- 




Fig. 57. — (1) Ethmoidal branch of the internal nasal nerve. 
(2) Nasopalatine nerve which supplies the wall and emerges 

through the anterior palatine foramen, behind the incisors. 
(Pauchet.) 



fice. In the case of the upper turbinate, however, 
their use is disadvantageous because it diminishes 
the already small area concerned. It is prefer- 
able, therefore, to infiltrate the affected tissues, as 
this augments their volume. In the presence of 
numerous polypi, tamponing is tedious and some- 
times impossible. We therefore inject the eth- 
moidal, nasal, and septal nerves, thus rendering 
the parts anesthetic (Fig. 57). 



82 



REGIONAL ANESTHESIA. 



Moure's Operation for Large Tumors 
OF THE Brain. 

(a) Application of cocaine tampons to the ol- 
factory mucosa; (b) infiltration of the ethmoidal 




Fig. 58. — Operation of Moure. Resection of the ethmoid 
after having displaced downward the ascending branch of the 
superior maxillary and enlarged the anterior orifice of the 
bones of the nasal fossa without regard to the superior maxil- 
lary. (A) Infiltration of the ethmoidal nerve by the internal 
orbital route. (B) Infiltration of the superior maxillary nerve 
(see Figs. 43 and 44). (C) Emergence of the infraorbital 
nerve. 



nerves; (c) infiltration of the superior maxillary 
nerve; (d) infiltration of the infraorbital nerve; 
(e) infiltration of a line from the corner of the 



ANESTHESIA OF THE HEAD AND NECK. 83 

mouth upward, as shown in Fig. 58. Peripheral 
infiltration following a broken line uniting the 
corner of the mouth with the junction of the 
superior maxillary nerve and the base of the nasal 
lobe. 



Injection of the Maxillary Sinus 
(Luc's Operation.) 

(a) Tamponing the nasal cavity with gauze 

soaked with cocaine; (b) infiltration of the eth- 




Fig. 59. — Trephining the maxillary sinus. (Laboure.) 
(1) Infiltration of the superior maxillary nerve at the foramen 
ovale (Figs. 43 and 44). (2) Anesthesia of the ethmoidal 
nerve by the internal orbital route (Fig. 41). The subcuta- 
neous infiltration is shown by the dotted lines. 



moidal and superior maxillary nerves; (c) infiltra- 
tion through the mouth of the canine fossa and the 
region of the infraorbital nerve (Fig. 59). 



84 



REGIONAL ANESTHESIA. 



Injection of the Frontal Sinus. 

(a) Tamponing the anterior superior nasal 
fossa with gauze soaked with cocaine; (b) infil- 
tration of the superior maxillary nerve; (c) infil- 




Figs. 60, 61. — Trephining the frontal sinus, one side and 
both sides. (Pauchet.) (1) Internal orbital injection (Fig. 
41). (2) Point of injection for the superior maxillary nerve 
(Figs. 43 and 44). Through the several dermal wheals, the 
field of operation is circumscribed along the dotted lines. 



tration of the ethmoidal nerves; (d) subcutaneous 
and preperiosteal injections surrounding the opera- 
tive field (Figs. 6o, 6i). 



ANESTHESIA OF THE HEAD AND NECK. 85 

Operations upon the Sphenoidal Sinuses and 
FOR Sarcoma of the Hypophysis. 

The endonasal route is followed; submucous 
resection of the cartilaginous and bony septum; 
infiltration of both sides of the septum and of 
the ethmoidal nerves. 



REGIONAL ANESTHESIA IN OTOLOGY. 
Nerve Supply. 

The middle ear receives its sensory supply 
from Jacobson's nerve, a branch of the glosso- 
pharyngeal, and the superficial petrosal nerve. 

The tympanum and external auditory canal are 
supplied by two nerves, which enter, the one an- 
teriorly, the other posteriorly. The anterior is 
the auriculo-temporal nerve, a branch of the supe- 
rior maxillary, which supplies the antero-inferior 
floor of the external canal. The posterior nerve 
is the auricular branch of the pneumogastric. 
These nerves enter the canal at the union of its 
cartilaginous and osseous portions. 

The external ear is supplied by the great auric- 
ular nerve, the auriculo-temporal, the lesser occip- 
ital, and the auricular branch of the pneumogastric. 

The nerve supply of the mastoid region con- 
sists of the sub-occipital and the superior cervical 
nerves, through branches from the mastoid. 

All of these nerve branches intercommunicate, 
and practically their respective limits are hard to 
define. 



86 REGIONAL ANESTHESIA. 



Technique. 



Anesthesia of the Middle Ear and Tympanum. 
— In the middle ear the nerves are superficial and 
sub-mucous, and can be desensitized with Bonain's 
solution : 

'^ Cocaine hydrochloride. 
Menthol, 

Phenol aa 1 grain. 

Adrenin 0.001 grain. 




^"^^a^ '.. -c '^ 



Fig. 62. — Anesthesia of the auditory canal. (Laboure.) 
The needle is introduced at the junction of the cartilage and 
bone on the superior and posterior walls. When it has pene- 
trated 2 millimeters, a 2 per cent, solution is injected. 



Upon application of this agent one may pain- 
lessly curette vegetations, remove a polyp, or 
puncture the tympanic membrane. 

For more severe procedures, such as ossiculec- 
tomy, the external auditory canal is anesthetized 
by the following procedure (Neumann) (Fig. 62): 



ANESTHESIA OF THE HEAD AND NECK. 87 

A large speculum is passed into the canal and 
inclined backward or laterally, thus bringing into 
view the point of junction of the cartilage with 
the bone. At this point, above and behind, at the 
junction of superior and posterior walls, a needle 
is inserted for 2 millimeters, a few drops of solu- 
tion slowly injected, and a bony contact felt for. 
The bone, when reached, should be followed for 
some distance in order to make certain of inject- 
ing the remainder of the solution into the sub- 
periosteal zone. Such an injection anesthetizes the 
upper portion of the tympanum, the vestibule, and 
the ossicles. One should wait 10 minutes before 
operating. 

The injection just described acts in the fol- 
lowing manner: On a level with Schrapnel's 
membrane, the two epithelial linings meet, the 
fibrous tissue of the tympanum being wanting. An 
injection of fluid following the epithelium of the 
canal penetrates under the epithelium of the mid- 
dle ear on a level with the flaccid membrane and 
ascends under the mucous membrane that lines 
the vestibule, since it is at no time arrested by 
any barrier (Molinar^). 

Anesthesia of the External Auditory Canal. — 
The external auditory canal is supplied by two 
nerves which penetrate in front and behind, at 
the union of the cartilaginous and bony portions 
of the canal. They can be reached either through 
the canal or from behind the auricle. 



1 Adolph Molinar : "'Regional Anesthesia for Operations upon the 
Auditory Apparatus." 



88 REGIONAL ANESTHESIA. 

The needle is directed backward toward the 
tympano-mastoid fissure in the direction of the 
pneumogastric. Procaine-adrenin solution is in- 
jected while introducing the needle. Then the 
latter is withdrawn i centimeter, without entirely 
removing it, directed downward, forward, and in- 
ward toward the condyle of the maxillary, and 




Fig. 63. — Showing a V-shaped injection, in its 
relations to the bony parts. 



during the course of this movement, 2 mils of 
procaine-adrenin solution injected to a depth of 
not more than 2 centimeters. After this pro- 
cedure, operations for furuncles or exostosis in the 
canal can be satisfactorily carried out (Fig. 63). 

Anesthesia of the External Ear and Mastoid 
Region. — Encircle the external ear and mastoid 
region with a series of injections which cross each 
other in the superficial and deep tissues (Fig. 64). 

It . is useless to try to penetrate beneath the 
periosteum; its close adhesion renders this impos- 



ANESTHESIA OF THE HEAD AND NECK. 89 

sible. Besides, such a procedure would be un- 
necessary. The bone receives its nerve supply 
from without, i.e., from the scalp. The operator 
may, if he so desires, inject along the line of the 
proposed incision. 




Fig. 64. — Anesthesia of the external ear. (Labonre.) 
Two wheals, superior and inferior, are made and injections 
executed in the direction of the arrows, describing a diamond- 
shaped figure about the ear. 



These various forms of anesthesia, viz., the ap- 
plication of Bonain's mixture to the tympanum or 
vestibule; infiltration of the vestibule through the 
canal; infiltration of the auriculo-temporal nerves 
and the auricular branch of the pneumogastric ; 
peripheral anesthesia around the external ear and 
mastoid, constitute a series of procedures neces- 
sary and sufficient for a number of different oper- 



90 



REGIONAL ANESTHESIA. 




Fig. 65. — Mastoidectomy. (Laboure.) A subcutaneous 
polygon is infiltrated through four wheals, the needle enter- 
ing in the direction of the arrows. 




Fig. 66. — Petromastoid operation. (Laboure.) After hav- 
ing infiltrated as in Fig. 65, three more wheals are made and 
injections executed in the direction of the two arrows (D) 
and the arrows (E and F). 



ANESTHESIA OF THE HEAD AND NECK. 91 

ations. One may employ one procedure, or an- 
other, or all procedures combined, according to the 
case. 

In general, the relative indications for each 
may be stated thus: i. For perforation of the 
tympanum: Application of Bonain's mixture, 
which drives the blood from the tissues and indi- 
cates to the operator the area anesthetized. 2. 
For ossiculectomy: Infiltration of the superior 
wall of the canal and vestibule, and application of 
Bonain's mixture. 3. For furuncle of the canal: 
Infiltration of the anterior and posterior nerves by 
an injection through the auriculo-mastoid sulcus. 
4. For plastic operations on the external ear: 
Peripheral anesthesia in circular form instituted 
around the external ear as a center. 5. For mas- 
toiditis: As in the preceding (Figs. 65, 66). 6. 
For curettage: A combination of all the preced- 
ing methods. 



REGIONAL ANESTHESIA IN OPHTHALMOLOGY. 

Nerve Supply. 

The orbit and ocular globe receive their nerve 
supply from the branches of the ophthalmic. In 
addition, the orbital branch of the superior maxil- 
lary supplies, through its terminal trunks — the 
temporo-malar nerves, — the skin of the temple, of 
the malar region, and about the external angle of 
the eye (Figs. 37, 38, 39). 



92 REGIONAL ANESTHESIA. 



Technique. 

Anesthesia of the ophthalmic nerve and its 
branches may be obtained by external and internal 
orbital injections, the technique of which has al- 
ready been described (Figs. 40, 41, 42, with 
several pages describing the ophthalmic and its 
branches). 

If necessary the anesthesia may be completed 
by infiltration of the superior maxillary nerve or 
of a few of its branches, as already described 
under Anesthesia of the Superior Maxillary. 

For completion of the anesthesia in respect of 
the ciliary nerves or the ciliary ganglion, the mus- 
cular pyramid which immediately surrounds the 
ocular globe should be infiltrated. In order to 
effect this, one should direct the needle toward the 
vault of the orbit, keeping as close as possible to 
the outer surface of the eye-ball. Five mils of a 
I per cent, procaine-adrenin solution are injected, 
and the sub-con junctival tissue also infiltrated. A 
needle is introduced into the external commissure 
of the eyelids, and pushed down between the con- 
junctiva and the bulb. Then, a little to the in- 
side, at a depth of 4j^ centimeters, i.e., close to 
the ciliary ganglion, i mil of a 2 per cent, solu- 
tion is injected. Finally J4 mil of this strong 
solution is injected under the conjunctiva sur- 
rounding the bulb. Thus, whatever be the oper- 
ation, — enucleation, etc., — perfect anesthesia will be 
obtained. 



ANESTHESIA OF THE HEAD AND NECK. 



93 



Operations on the Eyelids and Lachrymal 
Gland (Fig. 67). — A few drops of cocaine on the 
conjunctiva, together with an injection of 2 mils 
oi 3. ^2 per cent, solution of procaine-adrenin near 
the superior bony wall, will anesthetize the upper 
eyelid. 




Fig. 67. — Anesthesia of the eyelids. (Paiichet.) One injection 
through a wheal suffices for each eyelid. 



For the lower eyelid, one should inject 2 mils 
along the inferior orbital wall, in a fan-shaped 
area 2 centimeters deep and 2 across. The infra- 
orbital nerve, and the anterior ethmoidal, which 
supplies the internal portion of the lower eyelid, 
are infiltrated. 

Cataract; Iridectomy. — (a) Drop a few drops 



of a 



1/20 



per cent, solution onto the eyeball, sev- 



94 REGIONAL ANESTHESIA. 

eral times, as it will then act by absorption, (b) 
Inject yi mil of ^ per cent, solution procaine- 
adrenin under the conjunctiva. 

Eniicleation of the Eyeball. — (a) Inject 2 or 3 
mils of solution through the external superior 
angle, {b) Repeat this procedure at the internal 
angle, (c) Infiltrate the superior maxillary nerve 
either through the orbit or the malar region. 



REGIONAL ANESTHESIA IN DENTAL SURGERY. 
Nerve Supply 

As regards the upper teeth, the nerves first 
follow above the outer side of the tuberosity of 
the superior maxillary, then penetrate it in order 
to reach the dental pulp. Here they are dis- 
tributed also to the periosteum, the mucous mem- 
brane, and the alveolar tissue. 

The lower teeth are supplied by the inferior 
dental nerve, which enters the inferior maxillary 
bone at the inferior dental foramen and forms the 
inferior dental plexus, then divides into two 
branches, one in the bone, — the incisor, which 
supplies the incisor teeth, — the other,' the mental, 
which supplies the chin and lower lip. The lower 
gums and tongue are supplied by the lingual 
nerve. The region of the incisors is supplied by 
branches coming from the inferior dental, mental, 
and lingual nerves, all more or less inter-related. 



ANESTHESIA OF THE HEAD AND NECK. 95 



Technique. 

Iniiltration of the Dental Branches in the 
Upper Jazv. — A J^ per cent solution is used. 
From 2 to 10 mils suffices, according to whether 
it is desired to anesthetize one tooth or an entire 
half of the jaw. As the dental branches lie super- 
ficially, immediately under the mucous membrane 
in the fold of the gum, the injection is readily 
carried out and its result immediate. The point 
of injection varies according to the teeth to be 
rendered anesthetic: 

(a) For the incisors, one should infiltrate the 
submucous membrane in the median line, either on 
the level of the frsenum linguae or on the nasal 
floor near the septum, or at both of these points. 

{b) For the canine and first molars, the injec- 
tion is made above the canine tooth. 

(c) For the large molars, one infiltrates well 
back at the outer border of the tuberosity of the 
maxillary, and even at its posterior border if a 
curved needle is available. Again, it may be 
considered necessary to enter through the cheek, 
to a depth of 2^ centimeters, in the direction of 
the superior maxillary nerve. 

To permit of convenient infiltration, an aid 
should draw aside the labial commissures with 
small retractors. 

Where the work bears on half the maxillary 
arch, infiltration should be carried out along its 
entire length. 



96 . REGIONAL ANESTHESIA. 

On principle, one should not infiltrate the trunk 
of the superior maxillary nerve. Yet there need 
be no hesitation in doing so in cases of severe 
buccal septicemia. 

Infiltration of the Lower Teeth, — Where the 
incisors and canine teeth are concerned, one may 
proceed as for the upper jaw, infiltrating the sub- 
mucous membrane in order to reach the ramifica- 
tions of the mental and incisor nerves. 

For the remaining lower teeth this procedure 
is insufficient because the inferior dental nerve 
lies in the center of the maxillary bone, which is 
very thick at this point. One should, therefore, 
infiltrate the trunk of the nerve at the dental 
foramen as already described. The labial commis- 
sure is retracted, the ascending branch of the in- 
ferior maxillary nerve found, and 3 to 5 mils of 
a y2 per cent, solution of procaine injected into its 
center. (Figs. 55 and 56.) 

If the buccal cavity is too septic, the inferior 
dental nerve can be anesthetized from the outside; 
or 2 mils of anesthetic solution may be injected 
under the dental collar of the last molars in order 
to infiltrate the gingival branches of the buccina- 
tor — which, however, are not very large. 

Unilateral injections under the gums for the 
lower incisors are insufficient because of the anas- 
tomoses of the two incisor nerves. To obtain 
complete insensibility, both nerves must be infil- 
trated even for an operation involving only one 
side. Two mils of solution are injected on each 



ANESTHESIA OF THE HEAD AND NECK. 



97 



side of the median line; at this point there is 
a sHght depression, the thin, grooved wall of 
which permits of absorption of the procaine. 



REGIONAL ANESTHESIA OF THE 
FACE AND JAWS. 

The soft tissues of the face are supplied by 
the three branches of the trigeminus, the ramifica- 




Fig. 68. — The sensory areas of the head. (Testut.) (1) 
Ophthahnic. (2) Superior maxillary. (3) Inferior maxil- 
lary. (4.) Cervical plexus (anterior branches). (5) Cervical 
plexus (posterior branches). 



tions of which are so intermingled as to render 
trunk infiltration insufficient for complete anesthe- 
sia. Even infiltration of the Gasserian ganglion 
of one side yields only an incomplete anesthesia 
when the operative procedure is conducted near 
"^he median line. 

7 



98 



REGIONAL ANESTHESIA. 




Fig. 69. — The measurements of Offerhaus. The "tubercle 
line" C D passes a few millimeters in front of and below the 
foramen ovale at points A and B. The distance E F from one 
superior dental arch to the other, is equal to A B from one 
foramen ovale to the other. Measuring C D and E F, sub- 
tracting the latter from the former, and dividing the result by 
2 yields the distance C A or D B. This procedure constitutes 
an alternative method for injecting the superior maxillary 
nerve at the foramen ovale. (C/. pp. 72-74.) 



Anesthesia of the Midfrontal Region. 

The frontal zone is supplied by branches of the 
ophthalmic nerve, — lachrymal, frontal, and nasal, — 
which ascend from below. It is sufficient, there- 
fore, to institute a horizontal line of infiltration, 
both intradermal and subperiosteal, passing above 
the convexity of the two eyebrows (Fig. 40). 



ANESTHESIA OF THE HEAD AND NECK. 99 

Anesthesia of the Nose, Lips, and Cheeks. 

The lobe of the nose is easily rendered in- 
sensible by means of a circular infiltration outlin- 
ing its base (Figs. 70 and 71). Thus, in the 
case of a tumor of the lobe requiring surgical in- 
tervention, four injections should be made through 




Fig, 70. — Circumscribing the lobe of the nose. (Braun.) 

dermal wheals located as follows: One on the 
bridge of the nose, two at the base of the alse, 
and the fourth at the base of the nasal septum on 
the upper lip. 

The upper lip (Fig. 71) may be desensitized by 
three lines: One transversal, going from the base 
of one ala to the other, and the two others ver- 
tical, descending from the extremities of the pre- 
ceding points to the labial commissures and also 



100 



REGIONAL ANESTHESIA. 



ascending to meet at the bridge of the nose. Two 
bands of infiltration should thus be made, the one 
subcutaneous, the other submucous, the needle be- 
ing directed parallel with the mucous membrane 
by means of a gloved finger introduced under the 

lip. 




Fig. 71. — Anesthesia of the lobe of the nose and the upper 
lip through two wheals, following the direction of the arrows. 
(Pauchet.) 



Infiltration of the upper lip may usually be 
combined with that for the lobe of the nose. 
The anesthetized area may be enlarged at will ac- 
cording to the necessities of the operation (as in 
the pentagon, Fig. 72). 

For harelip one should infiltrate a band ex- 
tending from the commissure of the lips to the 



ANESTHESIA OF THE HEAD AND NECK. 



101 



infraorbital foramen, connected by a transverse 
line across the dorsum nasi. 

The anemia produced by the adrenin facilitates 
operative work. The tissues are not altered by 
peripheral infiltration made at a distance. 




Fig. 72. — Anesthesia for facial operations (Pauchet.) 
There are two median wheals, central and superior, and two 
lateral and inferior wheals. (5) and (6) serve for anesthesia 
of the infraorbital nerve. (4) applies in anesthesia of the 
ethmoidal nerve. The dotted polygon is a line of infiltration 
made with a 1 per cent, solution. 



For the lower lip a single dermal wheal should 
be made on the chin, and from this point two 
divergent lines of infiltration made both under the 
skin and under the mucous membrane, with the 
needle guided by a finger introduced in the mouth. 

The chin and subjacent symphysis menti some- 



102 



REGIONAL ANESTHESIA. 




Fig. IZ. — Median section of the body of the inferior maxil- 
lary. (Pauchef.) The anterior and posterior sections of the 
body of the maxillary bone are infiltrated through three wheals. 




Fig. 74. — Anesthesia for resection of the superior maxil- 
lary bone. (1) and (la) External and internal orbital injec- 
tions. (2) Injection of the superior maxillary nerve. A weak 
procaine-adrenin solution is used in instituting the subcuta- 
neous bands of infiltration. 



ANESTHESIA OF THE HEAD AND NECK. 



103 




Fig. 75. — Unilateral resection of the lower jaw (Pauchet.) 
The inferior dental nerve is injected at the inferior dental 
foramen, or the inferior maxillary nerve at the foramen ovale, 
and the subcutaneous tissue then infiltrated along the dotted 
line. 




Fig. 76. — Operation on the horizontal portion of the lower 
maxillary bone. (Pauchet.) The inferior dental nerve is 
anesthetized at the inferior dental foramen or the inferior 
maxillary nerve at the foramen ovale, and a subcutaneous 
diamond-shaped figure infiltrated through three wheals. The 
dark line indicates the incision. 



104 REGIONAL ANESTHESIA. 

times require to be rendered insensible, e,g., for 
the suture of a fracture of the mandible (Fig. 73) : 

(i) A horse-shoe-shaped band of infiltration 
following the lower border of the inferior maxil- 
lary bone, both subcutaneous and subperiosteal. 

(2) Infiltration of the mental nerve on one, or 
better both sides, even if the operation be uni- 
lateral. 

Resection of the Superior Maxillary (Fig. 74). 
— If the lesion is extensive and likely to cause the 
surgeon to go beyond the superior maxillary, he 
is justified in infiltrating the Gasserian ganglion, 
as already explained. Generally, however, it proves 
sufficient to proceed thus: (i) Infiltrate the supe- 
rior maxillary nerve. (2) Infiltrate the inferior 
maxillary nerve. (3) Infiltrate the orbital nerves 
by two injections in the superior-internal and 
superior-external angles. (4) Infiltrate the hard 
and soft palates, following the line of incision. 

For the lo\\'er jaw (Figs. 75 and 76) the in- 
ferior maxillary nerve should be infiltrated at the 
foramen ovale or at the dental foramen with a 
Yz per cent, solution and the field of operation 
circumscribed with peripheral injections of a i 
per cent, solution. One can then operate on the 
bone for suturing or resection. In the event of 
cancer at the alveolar border, the nerves should be 
infiltrated at the inferior dental foramen. For 
disarticulation of the jaw the foramen ovale should 
be infiltrated. ■ 



ANESTHESIA OF THE HEAD AND NECK. 



105 



REGIONAL ANESTHESIA OF THE TONGUE, FLOOR 
OF THE MOUTH, TONSILS, AND PALATE. 

Nerve Supply. 

The lingual nerve supplies two-thirds of the 
anterior portion of the tongue and the floor of 
the mouth; the glosso-pharyngeal nerve supplies 
the posterior portion of the tongue, the region of 




Fig. 11. — Sensory distributions on the tongue. {Tes- 
tut.) (1) Lingual. (2) Glossopharyngeal (3) Superior 
laryngeal. 

the tonsils, and the pharynx; the superior maxil- 
lary nerve supplies the soft palate and the ante- 
rior pillars of the fauces, and the superior laryn- 
geal nerve supplies the epiglottis. 

One may therefore infiltrate the following 
trunks : 

( I ) The lingual nerve, within the inferior den- 
tal foramen, desensitizing two-thirds of the ante- 
rior portion of the tongue and the floor of the 
mouth. 



106 



REGIONAL ANESTHESIA. 



(2) The superior laryngeal nerve, in the thyro- 
hyoid space (see page 116). 

(3) Infiltration of the glosso-pharyngeal and 
pneumogastric nerves should be avoided because 
it is dangerous; peripheral infiltration must be 
substituted. 

Technique. 

Excision of a Tumor of the Margin of the 
Tongue. — A triangle enclosing the tumor is out- 




Fig. 78. — Anesthesia of the tongue and the buccal floor. 
(Pauchet.) With a finger placed over the base of the tongue 
the needle is introduced above the hyoid bone until its point 
almost touches the finger on the tongue, coming to rest just 
beneath the mucous membrane. 



lined by two V-shaped bands of infiltration. The 
growth can then be excised without hemorrhage 
or pain. 

Excision of an Extensive Cancer or Large 
Cyst of the Floor of the Mouth. — A long needle 



ANESTHESIA OF THE HEAD AND NECK. 



107 



is introduced under the chin, above the hyoid bone, 
and pushed in vertically toward the base of the 
tongue, being received against the tip of the left 
index finger, introduced into the mouth as for tra- 
cheotomy. This vertical route is first infiltrated, 
then through the same wheal one injects succes- 
sively from top to bottom and further and fur- 
ther out, as many layers as are necessary to form 
a fan shaped infiltrated region, the sides of which 
extend to the maxillary bones, thus blocking off 




Fig. 79. — Injection for transverse incision of the cheek for 
cancer of the pharynx or posterior cancer of the tongue. 
{Pauchet.) 



all the nerves of the anterior portion of the 
tongue. 

Restricted Operations on the Floor of the Month. 
— Small tumors of the floor of the mouth may be 
infiltrated in a circle, by an injection made from 
under the chin, with the needle always guided by 
the finger in the mouth. 

Removal of Extensive Cancer of the Tongue, 
Floor of the Month, and Tonsils. — (i) The two 
inferior maxillary nerves are infiltrated at the in- 



108 



REGIONAL ANESTHESIA. 



ferior dental foramen: (2) the base of the tongue 
is infiltrated by a subhyoid injection; (3) peri- 
oheral infiltration of the operative field is insti- 







Fig. 80. — Tonsillectomy (Laboure.) The superior pole is 
infiltrated by an injection made in the upper part of the an- 
terior pillar. An injection at the base of this pillar infiltrates 
the inferior pole. Quinine is employed. 




Fig. 81. — Tonsillectomy. (Laboure.) The inferior pillar 
is completely infiltrated. Quinine infiltration of the tonsil has 
been instituted (white crescent) 

tuted; (4) in some cases the Gasserian ganglion 
of one side is also infiltrated. 

Operations on the Palate. — Anesthesia of both 
the soft and hard palate may be obtained by mak- 
ing an injection under the mucous membrane in- 



ANESTHESIA OF THE HEAD AND NECK. 109 

side of the large molars and behind the middle 
incisors. For resection of the bony hard palate, 
the two superior maxillary nerves should be in- 
filtrated. 

In staphylorrhaphies one should avoid using too 
much adrenin at the point where the flaps are to 
be made. 

Tonsillectomy (Figs. 80 and 81). — Infiltrate 
the two nerve pedicles of the tonsil : ( i ) At the 
lower portion of the anterior pillar; (2) at the 
upper part of the vestibule, at the junction of the 
posterior and anterior pillars. 

REGIONAL ANESTHESIA IN OPERATIONS 
ON THE NECK. 

Infiltration of the Cervical Roots. 

The soft tissues of the anterior portion of the 
neck are supplied by the anterior branches of the 
2d, 3d, and 4th cervical nerves, of w^hich the ter- 
minal branches^a?/n*cz//ar, mastoid, transverse cer- 
vical, and supraclavicular, — emerge at the posterior 
margin of the sterno-mastoid muscle (Fig. '^2). 

Infiltration of these terminal branches at the 
posterior border of the sterno-cleido-mastoid de- 
sensitizes the skin alone and this is rarely suffi- 
cient. In order to obtain a deep anesthesia, the 
nerves must be reached at their emergence from 
the spinal column, on a level with the transverse 
processes of the 3d, 4th, and 5th vertebrae (Fig. 86). 

The distribution of the cervical trunks is as fol- 
lows (see Figs. 85 and 87): The second cervical 



110 REGIONAL ANESTHESIA. 

supplies the nape of the neck and the occipital 
region. The third cervical supplies the antero- 




Fig. 82. — Superficial branches of the cervical plexus 
(Hirschfeld.) These branches should be desensitized by in- 
filtration of the soft tissues lying between the mastoid and 
the upper margin of the cricoid cartilage, following a ver- 
tical line and injecting through 3 wheals. 



lateral portions of the neck, from the lower jaw 
to the shoulders and the upper portions of the 
arms. The roots of the second, third, and fourth 



ANESTHESIA OF THE HEAD AND NECK. 



Ill 



cervical supply the cervical plexus (see Figs. 83 
to 85). It is these roots, therefore, that must be 
reached in operating on the neck. 

Technique. — The line of skin infiltration for 
the cervical plexus is vertical, i.e., parallel with 



Ophthalmic 




Greater 
occipital 

Mastoid branch 
of great auricular 



Occipital 
foramen 

Great auricular 



Third cervical 



Phrenic 



Supraclavicular 



Fig. 83. — Sensory areas of the superficial branches of 
the cervical plexus. (Testut.) 



the spinal column, and is determined by the two 
following points: Above, a point one finger- 
breadth below the tip of the mastoid, corre- 
sponding to the angle of the jaw; below, a point 
5 centimeters lower down and corresponding to 
the superior border of the thyroid cartilage. Using 
a 6-centimeter needle, the bone should be encoun- 



112 REGIONAL ANESTHESIA. 

tered at a depth of 5 centimeters, and a fan- 
shaped injection of a i per cent, solution of pro- 
caine-adrenin made there. About 25 mils is suffi- 
cient. The needle should be introduced through 




Fig. 84. — Anesthesia of the cervical plexus. (Pauchet.) 
On a line joining the mastoid and the tubercle of the 6th cer- 
vical transverse process (1 to 3) a layer of soft tissues, ex- 
tending from the skin to the spinal column and from the 
lower border of the inferior maxillary (1) to a point situated 
on a level with the cricoid (2), is infiltrated. 



the wheals indicated and the fluid injected as it 
is withdrawn. There is thus infiltrated an area 
about S centimeters square, outlined on the skin 
by the preceding line, above and below by a per- 
pendicular line passing from these points to the 
vertebral column, and involving the tissues bor- 



ANESTHESIA OF THE HEAD AND NECK. 



113 




Fig. 85. — x\iiesthesia resulting from paravertebral injec- 
tion of the cervical plexus (anterolateral and posterior view), 
(Testnt.) 




Fig. 86. — Paravertebral anesthesia of the neck. (Daiiys.') 
Needle (1) is aimed directly at the lateral portion of the ver- 
tebra, but it almost touches the vertebral artery. Needle (2) 
(Danys) enters 2 centimeters from the spinous process, comes 
in contact with the lateral mass of the vertebra, and reaches 
the nerve without danger to the vertebral artery. 

8 



114 



REGIONAL ANESTHESIA. 



dering the column between the two perpendicular 
lines (Fig. 84). 




.-r' 









.^-'T'^'s 



Fig. 87. — Paravertebral anesthesia of the neck. (Pauchet.) 
A B extends from the mastoid to the 6th cervical vertebra. 
The white and black dots indicate the dermal wheals. Along 
this line the needle enters transversely to infiltrate the nerve 
(direct route). The figure shows the needle penetrating ob- 
liquely (Danys) 2 centimeters beyond the spinous process and 
following the lateral masses of the vertebrae. As soon as it 
has passed these a strong solution of procaine-adrenin is 
injected. 



Danys advises that the needle be introduced 
through the posterior surface of the neck, 2 centi- 
meters from the interspinous line, in order to avoid 



ANESTHESIA OF THE HEAD AND NECK. 



115 



a possible penetration of the needle into the inter- 
transverse space and a consequent wounding of 
the vertebral artery. We prefer, however, the 
method described above, care being taken not to 
penetrate too deeply. 




Fig. 88. — Peripheral infiltration for laryngectomy or laryn- 
gotomy, circumscribing the larynx. (Laboure.) The wheals 
here shown should be joined by subcutaneous and subfascial 
bands of infiltration. The wheal corresponding to the thyro- 
hyoid space is missing from the polygon. Infiltration of the 
two superior laryngeal nerves through the thyro-hyoid mem- 
brane is sufficient. 



Anesthesia of the Laryngeal 
Nerve Trunks. 

Two nerves supply the larynx, — the superior 
laryngeal, and the inferior or recurrent laryngeal. 
The latter is almost exclusively motor, whereas 
the first is entirely sensory (Fig. 88). 



116 REGIONAL ANESTHESIA. 

Infiltration of the Superior 
Laryngeal Nerve. 

The superior laryngeal arises from the in- 
ferior pole of the plexiform ganglion. It is held 
against the pharynx by the internal carotid, then 
by the beginning of the facial and lingual arteries, 
Slightly above the greater cornu of the hyoid bone 
it divides into its two terminal branches: 

(i) The superior branch {external laryngeal) 
follows the vertical insertion of the inferior con- 
strictor over the thyroid gland to the crico-thyroid 
muscle, which it supplies, and terminates in the 
subglottic portion of the mucous membrane of the 
larynx. 

(2) The inferior branch {internal laryngeal) 
continues in the direction of the common trunk, 
passes between the thyroid muscle and the hyo- 
thyroid membrane, penetrating through the middle 
of this membrane, and divides into superior ter- 
minal filaments for the epiglottis and base of the 
tongue, inferior filaments for the mucous membrane 
of the larynx and the arytenoids, and an anasto- 
motic termination for the recurrent nerve (ansa 
Gallieni). 

Technique. — The sensory innervation of the 
larynx is constituted almost entirely, — above the 
vocal cords at any rate, — by the superior laryn- 
geal. As already stated, this nerve penetrates im- 
mediately behind the posterior extremity of the 
greater cornu of the hyoid bone, under the in- 
ferior border of this bone. It follows closely the 
thyro-hyoid membrane, courses forward, perforates 



ANESTHESIA OF THE HEAD AND NECK. 117 

this membrane, and supplies the laryngeal mucous 
membrane and the neighboring portions of the 
pharynx. A needle 6 centimeters long is intro- 
duced in the median line between the thyroid car- 
tilage and the hyoid bone, into the thyroid liga- 
ment. Once it is in this ligament, the needle is 
made to approach the greater cornu of the hyoid 
bone, which is easily felt with the finger. This 
ligament is now infiltrated on both sides, to the 
right and to the left, with 5 to lo mils of a i 
per cent, procaine-adrenin solution. 

Infiltration of the Recurrent Laryngeal Nerve. 
— Even if this nerve were exclusively motor, its 
infiltration would be justified to avoid spasm of 
the larynx, but actually it is a mixed nerve. 
Couzard and Chevrier infiltrate it thus: "Intro- 
duce a straight needle into the angle formed in 
the median line by the superior border of the thy- 
roid, injecting obliquely below, behind, and out- 
side of the angle; come into contact with the in- 
ternal face of the thyroid cartilage; guide the 
needle diagonally toward the postero-inferior angle 
of this cartilage, and inject the solution; it will 
distend the recess and bathe the terminal branches 
of the recurrent nerve." One to 2 mils of solu- 
tion suffices. 

These infiltrations of the trunks do not render 
local anesthesia unnecessary. Spraying with a 20 
per cent, solution of cocaine, tamponage with a 10 
per cent, solution, and submucous injection of i 
per cent, procaine-adrenin, are all advantageous 
adjuncts. 



118 REGIONAL ANESTHESIA. 



Operations. 



(i) Eridolaryngeal Intervention. — {a) One should 
first anesthetize by spraying and tamponing with 
a lo to 20 per cent, solution of cocaine the base 
of the tongue, the pillars of the fauces and the 
larynx. 

(h) Infiltration of the two superior laryngeal 
nerves should be carried out. 

(2) Tracheotomy, Laryngo-Hssure, and Laryn- 
gostomy. — The methods of anesthesia described 
above should be employed, and intradermal and 
subcutaneous, peripheral, and trunk anesthesia 
added. In cases of laryngo-fissure and laryngos- 
tomy, as soon as the larynx is open, one may 
apply tampons moistened with a strong solution of 
cocaine to the mucous membrane. 

(3) Laryngectomy and Goiter Operations. — 
These are more extensive procedures, for the per- 
formance of which it is necessary to infiltrate the 
trunks of the nerves of the plexus and the larynx, 
and to institute a subcutaneous peripheral infiltra- 
tion surrounding the larynx or the tumor at a 
distance. 

The harmful actions of chloroform or ether 
upon the heart, lungs, and liver are thus avoided, 
to the great benefit of patients whose respiration is 
afifected by disease or who are diabetic. Again, 
regional anesthesia permits the patient to clear his ^ 
bronchi during the course of the operation, thus 
avoiding broncho-pneumonia. Shock is also con- 
siderably diminished. 



ANESTHESIA OF THE HEAD AND NECK. 



119 



(4) Ligation of the External Carotid or Thy- 
roid Arteries. — The cervical plexus is first infil- 
trated, and there is then circumscribed under the 
skin and fascia a quadrilateral area extending 
beyond the limits of the incision. 

(5) Removal of Enlarged Glands and Tumors 
of the Neck. — The cervical plexus of one or both 




Fig. 89. — Infiltration for thyroidectomy. (Pauchet.) The 
injection to the right infiltrates the branches of the cervical 
plexus along the transverse processes of the vertebrae (from 1 
to 2). The mass is surrounded at a distance with a sub- 
cutaneous and subfascial band of infiltration (2, 3, 4, 5, and 6). 
We have performed about 250 strumectomies by Kocher's 
method without mortality. 



sides is infiltrated and the tumor or lymphatic 
mass circumscribed by peripheral injection of a ^ 
per cent, procaine-adrenin solution. If the mass 
of the tumor or lymphatics extends posteriorly so 
as to interfere with the passage of the needle, 



120 



REGIONAL ANESTHESIA. 



the latter may, instead of being introduced trans- 
versely or in front, be passed in near the inter- 
spinous line, in an anterior or in any intermediate 
oblique direction. 

(6) Infrahyoid and Suprahyoid Pharyngotomy. 
— The thyroid membrane is infiltrated and a peri- 





y^^ 


HH^^Ki. 


m^ 


' -' H '"""^^^^H 






^^'imB 


\:3M^i^^-^ 


^^JM ■■' 


■'m-'- 


-m 



Fig. 90, — Removal of carcinoma of the larynx under 
regional anesthesia. (Pauchet.) The organ has been opened 
up posteriorly; the tumor is to be seen on the right vocal cords. 



pheral lozenge-shaped area of infiltration made 
over the inferior maxillary and the thyroid car- 
tilage. During the course of the operation it is 
sometimes necessary to infiltrate the tumor over 
its entire external surface. 



ANESTHESL\ OF THE HEAD AND NECK. 



121 



(7) Thyroidectomy. — Six dermal wheals are 
made (Figs. 89 and 90). Points i and 2 cor- 
respond to the line of the transverse processes 
and serve as landmarks in instituting paraverte- 
bral anesthesia of the neck. All the tissues, epi- 
dermis, muscles, and nerves are thus infiltrated 
until the cervical plexus is reached. 




Fig. 91. — Paravertebral anesthesia of the neck. (Danys.) 
This figure shows the two methods of reaching the nerve as 
it emerges from the spinal canal. Needle 1 aims transversely 
for the nerve, but it runs a risk of injuring the artery. Needle 
2 enters 2 centimeters from the median line, follows the line 
of the vertebrse, comes in contact with the transverse process, 
and finally reaches the nerve, while avoiding the vertebral 
artery. 



With a needle 9 centimeters long, a subcuta- 
neous and subfascial band is infiltrated through 
the dermal wheals (Figs. 89 and 90). One 
hundred grams of a }^ per cent, solution of pro- 
caine-adrenin are required. This procedure may 
also be employed in the removal of malignant 
tumors. 



122 



REGIONAL ANESTHESIA. 



(8) Total Laryngectomy. — A subcutaneous hexa- 
gon is made, extending from a point slightly 
above the hyoid bone to the angle of Louis. A 




♦Vs^V^^^» 



Fig. 92. — Infiltration of the anterior aspect of the neck. 
{Lahoure.) This is intended for major operations in this 
region, e.g., for cancer of the larynx, goiter, extirpation of 
lymphatics of the neck for cancer of the tongue, etc. A, B, C, 
and D indicate the method of paravertebral injection of the 
cervical nerves. Dermal wheals are made above and below 
to circnmscribe the operative field. 



paravertebral infiltration is then conducted through 
two dermal wheals, as in goiter, for the purpose 
of anesthetizing the transverse cervical branch. 



ANESTHESIA OF THE HEAD AND NECK. 



123 



11^ 



■^^ 







^|R.. 







Fig. 93. — Large adamantoma of the lower maxillary. (Pauchet.) 
On the lower part of the tumor is seen a white, cross-shaped scar, — • 
evidence of an operation carried out a few years before. This case 
had been recently diagnosed "inoperable sarcoma." The tumor com- 
municated with the mouth and secreted pus abundantly. Insomnia. 
Liquid diet. Anesthesia was commenced by paravertebral injection of 
the cervical plexus, injection of the superior maxillary nerve by the 
orbital route, and simple infiltration of the chin and lower lip in the 
median line. These three anesthetizing injections enabled the operator 
to hgate the external carotid and perform a section from the middle of 
the neck to a point beyond the eyelid, extending through the chin and 
cheek (see the succeeding figures). 



124 



REGIONAL ANESTHESIA. 



Finally, the superior laryngeal nerve is anesthe- 
tized. One must not forget to spray the pharynx 




Fig. 94. — Second stage of the operation : Ligation of the 
external carotid has been effected. The scalpel has just 
divided the skin in front of the tumor. 



with cocaine, in order to suppress the reflexes of 
deglutition and prevent coughing. Two hundred 
to 250 grams of a ^ per cent, solution of pro- 
caine-adrenin are required for this operation. 

It is in cases such as these that regional anes- 
thesia exhibits its superior degree of utility. 



ANESTHESIA OF THE HEAD AND NECK. 125 




Fig. 95. — Third stage : Resection of the jaw has been completed. 
To the left is still seen the needle which has served to infiltrate the 
foramen ovale (inferior maxillary). The external carotid having been 
previously ligated, there is not much hemorrhage. 



126 



REGIONAL ANESTHESIA. 




Fig. 96. — Anesthesia by infiltration of the cervical plexus and 
superior and inferior maxillary nerves. (Pauchet.) An esophageal 
tube has been introduced in the nose. The patient is to be fed 
through it. 



ANESTHESIA OF THE HEAD AND NECK. 127 




Fig. 97.~Anesthesia of the cervical plexus and inferior maxillary 
nerve for amputation of the tongue by the subhyoid route. (Pauchet.) 
The infrahyoid floor has been incised, and the tongue drawn out. 



CHAPTER V. 

ANESTHESIA OF THE THORAX AND ABDOMEN. 

Operations upon the trunk may be performed 
under spinal anesthesia by means of cocaine (Le 
FilHatre) or other drugs introduced more or less 
high up (Jonnesco) after a series of paraverte- 
bral injections, which constitutes the ideal regional 
anesthesia for the upper portions of the trunk, or 
by lumbosacral injections (Le Filliatre). For in- 
tra-abdominal operations and operations in the pel- 
vis and on the lower extremities, injection of procaine- 
adrenin directly into the lumbar canal offers the 
simplest and most complete form of anesthesia. 



Intraspinal Anesthesia. 

Personally we prefer regional anesthesia for all 
operations upon the head, face, neck and thorax, 
as well as all other operations of a local charac- 
ter. But for amputation, resection or other ex- 
tensive procedures on the lower extremities, as 
well as for major intra-abdominal operations on 
the liver, stomach, intestines, and pelvic organs, 
intraspinal anesthesia possesses certain pronounced 
advantages. It is particularly valuable in opera- 
tions for intestinal occlusion, as it paralyzes and 
softens the abdominal wall and contracts the in- 
testine, practically eliminating the risk of fecal 
(128) 



THORAX AXD ABDOMEN. 129 

vomiting and thereby aiding toward a favorable 
prognosis. 

We do not advocate intraspinal anesthesia for 
any operation in which regional anesthesia is in- 
dicated, e.g., in hemorrhoids, varicocele, perineor- 
rhaphy, prostatectomy, amputation of the foot, suture 
of the patella, nephrectomy, cholecystotomy, and 
all operations on the head, neck and thorax. 

The spinal cord proper terminates at about the 
level of the junction of the second and third lum- 
bar vertebrae, where it becomes filiform. It is 
entirely safe to inject directly into the spinal canal 
at the space between the third and fourth (Tuf- 
fier), fourth and fifth (Chaput), and fifth lumbar 
vertebra and sacrum (Le Filliatre), and, with a 
little care not to enter the cord, between the first 
and second lumbar vertebrae. 

Injection into any one of the inter-vertebral 
spaces of the lumbar region produces insensibility 
of the lower part of the abdomen and the lower 
extremities. 

Under this form of anesthesia we have per- 
formed, at the ]\Iolitor Hospital, operations iipon 
every portion of the leg and thigh. 

Some little familiarity and practice is required 
for the successful injection of the spinal region. 
It is easiest to find entrance to the canal between 
the last lumbar vertebra and sacrum, because here 
the space is wide, but as a matter of fact, it is 
not difficult to effect an entrance at any one of 
the interspaces mentioned. 



130 REGIONAL ANESTHESIA. 

Injections into the spinal canal are greatly 
facilitated by placing the patient in a sitting posi- 
tion with head bent over on the arms — the latter 
folded upon the knees, — and the back made to 
''bow'' as much as possible in order to throw the 
spinous processes into the greatest possible promi- 
nence. 

The same degree of aseptic precaution should 
be taken for injecting the spinal canal as for a 
laparotomy, both as regards the surgeon and the 
patient. 

A strong needle of rather large caliber, 8 
centimeters long, should be selected. With the 
index finger of the left hand the space to be injected 
is found, Yz centimeter from the median line of 
the spine, midway between two adjacent spinous 
processes. In the center of this space the needle 
is introduced in a straight line, pointing slightly 
inward toward the median line (Fig. 98). At a 
certain depth, which varies according to the con- 
formation of the patient, the operator senses con- 
tact with the ligamenta subflava and the inter- 
laminar ligament, some force being required to 
penetrate and the operator experiencing somewhat 
the sensation of piercing a tense drum head. As 
the needle is pushed through, the silver wire is 
removed from its lumen from time to time to see 
if a drop of cerebrospinal fluid will appear. When 
the fluid drops more or less rapidly, according to 
the intraspinal tension, the syringe, containing 2 
mils of a 4 per cent, solution, is adjusted, the 
spinal fluid slowly drawn out to complete exten- 



THORAX AND ABDOMEN. 



131 



sion of the syringe, the fluid then slowly injected 
in part, and the piston redrawn and reinserted 
several times to mix the solution with the spinal 
fluid and cause it to be more generally diffused 




— J.— i^_-j. 



Fig. 98. — Showing point of entrance into the spinal 
canal, (Pauchet.) 



in the spinal canal. When the syringe has been 
finally emptied into the canal, the needle is with- 
drawn by a quick movement, slipping the index 
finger of the left hand over the puncture for a 
moment, then touching it with a drop of iodine 
tincture. In from five to fifteen minutes the pa- 



132 REGIONAL ANESTHESIA. 

tient will experience complete insensibility of the 
parts supplied by the nerves involved. 

If the injection be made between the 12th dor- 
sal and 1st lumbar vertebrae, it will produce a 
complete anesthesia of the abdominal contents — 
stomach, liver, intestines, abdominal walls — as well 
as the lower extremities. If it be made between the 
filth lumbar and sacrum it will anesthetize the 
perineum, anus and lower extremities. Both to- 
gether are recommended for abdomino-pelvic oper- 
ations such as hysterectomy or extensive extirpa- 
tion of the rectum (Jonnesco). 

For feeble, old individuals, and the cancerous, 
cachectic, and tuberculous, it is not necessary to 
employ the full strength of dose, as for the vigor- 
ous patient. The anesthesia is more readily in- 
duced in the feeble. 

As a precautionary measure it is well to in- 
ject, one hour before the operation, an ampoule 
of scopolamine-morphine and one of strychnine or 
sparteine. 

Equalization of the effect of the anesthetic is 
greatly facilitated by the repeated filling and par- 
tial reinjection of the contents of the syringe into 
the spinal canal. If this movement is not readily 
performed and something seems to prevent an 
easy flow to and from the syringe, the action of 
the anesthetic is likely to be imperfect. 

Immediately after the injection is made the pa- 
tient should be placed recumbent upon the opera- 
ting table and covered warmly. For him to re- 
main sitting up involves risk of an attack of syn- 



THORAX AND ABDOMEN. I33 

cope. The ears should be stopped with cotton, 
the eyes bandaged, if necessary, and complete 
silence ordered. The anesthesia continues for an 
hour or more. 

Complications. — (a) If cerebrospinal fluid fails 
to flow from the needle, either the direction of 
the needle is bad and the point has not penetrated 
the spinal canal, or the needle is plugged. Only 
two or three attempts are required for the oper- 
ator to feel confident when he is traversing the 
inter-laminar ligaments separating the vertebrae. 
If he be satisfied that the direction of the needle 
is not at fault, the needle should be withdrawn, 
aspirated with the aid of a syringe, and reintro- 
duced. 

(b) If pure blood appears, the needle has pene- 
trated a vein and must be withdrawn and rein- 
troduced. If the liquid is mixed with blood, one 
should wait a moment for the fluid to become 
clear. To inject with bloody fluid destroys the 
effect of the anesthetic. 

(c) If the liquid appears only in slow drops 
and will not fill the syringe when aspiration is 
made, it is useless to push the attempt farther. 
The needle must be withdrawn, its lumen cleared 
with the aid of a syringe, and the needle then re- 
introduced. 

(d) Incomplete anesthesia or absence of anes- 
thesia is due to one of the preceding errors. It 
does not occur in the hands of an experienced 
operator. 

Untozvard SeqiielcE. — (a) Retention of urine 



134 REGIONAL ANESTHESIA. 

may be present for several days. The patient oc- 
casionally requires daily catheterization for a week 
or more. 

(b) Vomiting after the operation is very un- 
common. 

(c) Sciatic neuralgia occurs when the operator 
introduces the needle to the outer side of the 
vertebra and pierces a nerve. 

(d) Headache often follows the injection and 
lasts a week. If it is violent, lumbar puncture is 
necessary. 

(e) Fecal incontinence during the operation. 
In the case of a total hysterectomy, this is danger- 
ous as the fecal matter may penetrate the vagina 
and enter the abdominal cavity. It is wise to 
tampon the vagina to safeguard against this 
difficulty. 

(/) Fever. The temperature may rise and fall 
on the first or second day; this is devoid of sig- 
nificance. 

(g) Labored respiration and asphyxia have 
appeared where the injections have been made 
high up and the anesthetic has afifected the center 
of respiration. If the mind is clear, the patient 
should be made to talk incessantly and draw in 
and blow out the air. If necessary, artificial res- 
piration should be resorted to. As soon as the 
effect of the anesthetic on the medulla has passed 
oil, natural respiration will be re-established. 

(h) Death. Among 2000 cases Pauchet has 
met with 2 deaths. In 5000 cases, Jonnesco had 



THORAX AND. ABDOMEN. 135 

no death. Le Filliatre has had no deaths, either. 
Leyden has had 2 deaths. I consider spinal anal- 
gesia as involving the same degree of immediate 
danger as does chloroform. 

(i) Nervous Manifestations. Among 5000 
cases Jonnesco observed but one case of nervous 
disturbance. Pauchet met with one case of blad- 
der retention which continued for three months. 
Organic affections not discovered by previous ex- 
amination may, of course, exist, and it is cer- 
tainly unjustifiable to attribute accidents appearing 
a year or more after the operation to the effects 
of the anesthetic. 

Regions Influenced. — Jonnesco has boldly prac- 
tised injection into the spinal canal along its 
whole length and specifies the effects of the anes- 
thetic in the various regions as follows : — 

(i) Injection between the 3d and 4th cervical 
vertebrae: Anesthesia of the head and neck. 

(2) Cervico-dorsal injection, immediately below 
the vertebra prominens: Thorax and upper ex- 
tremities. 

(3) Between the last dorsal and first lumbar: 
The entire abdomen, testicles, and lower ex- 
tremities. 

(4) Between the last lumbar and the sacrum: 
The pelvis, perineum, and anus. 

Injection at two points has been recommended 
for certain operations, viz., in operations upon the 
thorax, one may inject at the cervico-dorsal and 
dorso-lumbar levels. For abdomino-pelvic opera- 



136 REGIONAL ANESTHESIA. 

tions, one should inject at the dor so-lumbar and 
lumbo-sacral levels. For other operations, one 
injection suffices. 

Pauchet says: "I do not practice injection of 
the spinal canal at a point above the intersection 
of the 1 2th dorsal and ist lumbar, which insen- 
sibilizes the whole abdomen and its wall, prefer- 
ring regional and local anesthesia for all opera- 
tions above this level." 

As in the administration of chloroform, a cer- 
tain degree of danger attends the practice of spinal 
anesthesia, but the procedure is free of the post- 
operative dangers incident to general narcosis. It 
does not affect the viscera (lungs, liver, kidneys, 
or suprarenal capsules) and permits of highly 
traumatic operations (resection of the femur, dis- 
articulation of the hip) with very minor evidences 
of shock. It renders the major abdominal opera- 
tions more benign because it makes them easier, 
serving to contract the intestine, reducing com- 
pletely the rigidity of the abdominal wall, and pro- 
ducing complete "abdominal silence." 

There is no comparison between an operation 
for uterine cancer, for cancer of the rectum, and 
notably for acute occlusion of the intestine, under 
spinal anesthesia and under general narcosis. 

Nerve-trunk Anesthesia. 

The thoracic nerves emerge from the interver- 
tebral foramina of the thoracic portion of the 
spine (Fig. loi). Immediately after their emerg- 



■ THORAX AND. ABDOMEN. 137 

ence they give an anastomotic branch to the sym- 
pathetic, and afterward divide into two branches: 
an ajiterior and a posterior. The posterior branch 
suppHes the muscles of the back and skin in the 
vicinity of the midhne. The anterior branches or 
intercostal nerves are situated in the intercostal 
spaces near the inferior borders of the ribs. They 




Fig. 99. — Intercostal nerves and their distribution. (Hirsch- 
feld.) These nerves can be blocked by paravertebral injection 
or by simple intercostal injection. 

are at first in contact with the pleura, near the 
costal angle; afterward they pass between the two 
intercostal muscles (Figs. 99 and 100). 

The upper dorsal nerves (Fig. 103, D. i, 2, 
and 3) supply the internal surfaces of the arm 
and of the forearm, and the axillary and mam- 
mary regions are supplied likewise by the succeed- 
ing nerves, down to the seventh dorsal (D. 7), 
inclusive. The intercostal nerves from the 8th to 
the 1 2th supply the thorax, and likewise the ab- 



138 



REGIONAL ANESTHESIA. 




Fig. 100. — Intercostal and lumbar nerves and their distribu- 
tion. (Hirschfeld.) The figure shows the anastomosis of 
these nerves with the sympathetic. The needle is introduced 
close enough to the vertebral column to infiltrate the com- 
municating ramus, the viscera being thus anesthetized. 



THORAX AND ABDOMEN. 



139; 




Fig. 101. — The dorsal nerves at their points of emergence. 
(Testut.) The figure shows their bifurcation into an anterior 
branch (intercostal) and a posterior branch which divides into 
two rami. 



¥i: 



m 



Fig. 102. — The intercostal space. (Souligoux.) (A) Pos- 
teriorly at the point of origin. (B) At the posterior third. 
(C) Middle portion. The internal intercostal divides to sur- 
round the blood-vessels and nerves. 



140 



REGIONAL ANESTHESIA. 




Fig. 103. — Dorsal paravertebral anesthesia for the viscera. 
{Pmichet.) The operator is shown the dorsal points which should be 
infiltrated in order to anesthetize corresponding viscera. In practice, 
one should inject both higher and lower because of the anastomoses. 
The lung, kidney, biliary passages, and spleen are anesthetized by an 
injection made upon one side only. For other organs both sides 
should be injected. 



THORAX AND ABDOMEN. 



141 



domen. Through their anastomoses with the sym- 
pathetic, they supply with sensation the following 
viscera: Heart (Fig. 103, D. i, 2, and 3); lungs 



\. 




Fig. 104. — The lumbar nerves at their points of emergence. 
(Pauchet.) These nerves are accessible between the trans- 
verse processes of the lumbar vertebrae, as are the intercostals 
below the ribs. 



(D. I, 2, 3, and 4); stomach (D. 6, 7, 8, and 9); 
liver and bile ducts (D. 7, 8, 9, and 10); intes- 
tines (D. 9, 10, II, and 12); kidneys and ureters 
(D. 10, II, and 12); testicles, ovaries, and uterus 



142 



REGIONAL ANESTHESIA. 



(D. 10, II, and 12). To desensitize the viscera 
it is necessary to reach the anastomoses with the 
sympathetic ( Danys ) . 

The himbar nerves are situated between the 
transverse processes of the lumbar vertebrae in 
front of the intertransverse muscles, and are sur- 
rounded by the attachments of the psoas muscle 
(Figs. 100, 104, 105). 




Fig. 105. — The lumbar nerves at their points of 
emergence. (Hirschfeld.) 



The Uio-hypogastric, ilio-inguinal, and genifo- 
crural nerves^ supplying the anterior abdominal wall, 
follow, as the 12th intercostal nerves, the anterior 
surface of the quadratus lumborum, i.e., course 
between this and the perirenal adipose tissue. 
After the 2d lumbar, the nerve trunks are so 
closely applied against the vertebrae that they can 
only be reached by injections made almost in con- 
tact with the vertebral column at a distance of 3 
centimeters from the median line. 

The intercostals and the ist lumbar nerve sup- 
ply not only the thoracic and abdominal wall, but 



THORAX AND ABDOMEN. 143 

also the serous membranes, the pleurae, and the 
parietal peritoneum. The intermediate intercostal 
nerves do not anastomose at their points of origin, 
but from the 12th there is given off a branch to 
the 1st lumbar nerve. At the level of the skin the 
regions supplied by the respective intercostals so en- 
croach one upon the other that the blocking of a 
single nerve does not abolish cutaneous sensation; 
several must be infiltrated at the upper part of the 
thorax to obtain complete anesthesia of a given 
region. The skin of the thorax also receives 
branches from the cervical and brachial plexuses. 

The anesthesia required for operations upon 
the spine, thorax, and abdomen may be obtained 
by one of two methods. 

In the case of a circumscribed operation, such 
as resection of one or two ribs, curettage of the 
sternum, operation for appendicitis, for simple her- 
nia, etc., injections made along the course of the 
nerves supplying the field of operation, as des- 
cribed further on, will yield a complete anesthesia 
limited to the parietes. Such injections are made 
around, and at some distance from, the field of 
operation. The procedure varies for each opera- 
tion in accordance with the nerve supply. This 
method has enabled us to dispense with general 
and spinal anesthesia for a number of operations, 
e.g., in the radical cure of most voluminous her- 
nias. It appears to us the ideal procedure for 
thoracotomy, and is sufficient for appendectomy 
when the acute attack has subsided and provided the 
appendix and cecum are free from adhesions. It en- 



144 REGIONAL ANESTHESIA. 

ables us to do pylorectomy for cancer and very consid- 
erable resections of the intestines, provided the 
mesentery is injected in addition with a i per 
cent, solution of quinine and urea hydrochloride. 
When the operation concerns unilateral viscera 
— kidneys, liver, spleen, bile ducts, — or any larger 
portion of the trunk or abdomen, it is preferable 
to employ the following method, which is more 
precise in technique and permits of covering a 
larger field, viz. : — 

Paravertebral Anesthesia. 

Definition. — Paravertebral anesthesia consists in 
bathing the thoracic and lumbar nerves at their 
points of emergence from the intervertebral fora- 
mina of the dorsal and lumbar spine with a solu- 
tion of procaine-adrenin. The injection anesthe- 
tizes the thoracico-abdominal wall and even the 
viscera through the anastomoses with the sympa- 
thetic. By injecting a i per cent, solution of 
procaine-adrenin 3 to 4 centimeters from the 
median line in the intervertebral spaces the sur- 
geon is enabled to produce complete anesthesia of 
the thoracico-abdominal wall as well as of the 
unilateral viscera situated on the same side and 
receiving filaments of the sympathetic (liver, bile 
passages, spleen, kidneys, ureters). 

If the operator desires to anesthetize the entire 
abdominal contents (intestines), two series of in- 
jections will have to be made, one to the right 
and the other to the left of the spinal column; 



THORAX AND ABDOMEN. 



145 



but such an event is exceptional. Paravertebral 
anesthesia is useful for operations upon the thorax, 




Line of skin 
Infiltration 



Fig. 106. — Dorsal paravertebral anesthesia. (Paiichet.) 
The skin is infiltrated with a band 1 centimeter wide at a dis- 
tance of 35 millimeters from the median line. The operator 
introduces the needle through this band and feels his way. 
The black dots show where the needle should enter to reach 
the rib, somewhat laterally to the costo-vertebral articulation. 
AVhen the needle has come in contact with the rib, it turns 
about its inferior border and proceeds toward a point Yz centi- 
meter further forward and inward to reach the sympathetic 
anastomosis. It should be noted that the lower angle of the 
scapula corresponds to the spinous process' of the seventh dor- 
sal and the spine of the scapula to the third dorsal. 



neck and abdomen, the breasts, pleurae, lungs, and 
for lateral viscera, including the kidneys, liver, 
biliary passages, pylorus, cecum, etc. 

10 



146 REGIONAL ANESTHESIA. 

Technique. — The operator should remember that 
the thoracic nerves at their origin are located at 
equal distances from the transverse processes and 
at a distance of 2 centimeters in front of the 
intertransverse space. 

The spinous processes from the first to the 
sixth are situated at the level of the intertrans- 
verse spaces, bounded by the two succeeding ver- 
tebrae, and at the level of the nerve immediately- 
following. Thus, the processes D. i to D. 6 (Fig. 
106) correspond to pairs D. 2 to D. 7. The 
processes D. 7 to D. 12 are situated opposite the 
lower portion of the corresponding intertransverse 
space (Fig. no). 

The lumbar nerves, at their emergence from 
the conjugate vertebral foramina, are situated at 
the level of the corresponding spinous process and 
slightly above the transverse process of the ver- 
tebra immediately following (Fig. 104). They are 
therefore accessible through the intertransverse 
spaces at a distance of about 3 centimeters out- 
side the median line, and are situated / centimeter 
in front of the transverse processes (Fig. 106 
and 107). 

For the Dorsal Nerves. — A needle 6 to 9 centi- 
meters long is introduced at a point 3J/2 centi- 
meters from the median line. At a depth of 4 to 
5 centimeters, when the needle touches the rib, 
transverse process or costo-vertebral articulation, 
its point is inclined to reach the lower border of 
the bone. Then, at an angle of 25°, it is aimed 
at the middle line, and its progress terminated 



THORAX AND ABDOMEN. 



147 



Yz a centimeter beyond. Next, 5 mils of the 1.5 
per cent, solution is injected, or 7 to 8 mils of 
the I per cent, solution. It is well to move the 




Fig. 107. — Intercostal or paravertebral dorsal anesthesia. 
(Pauchet.) The first needle is directly in the intercostal space 
and in the vicinity of the nerve. The second (dotted line) 
has at first come in contact with the rib, but has then been 
given an oblique direction downward and has reached the 
vicinity of the nerve. 



point of the needle to and fro in order to be sure 
that the nerve is well bathed and to include the 
anastomosis of the sympathetic and the posterior 



148 



REGIONAL ANESTHESIA. 



as well as the anterior branch of the spinal root 
(Fig. io8). 

Two difficukies may arise: 




Fig. 108. — Paravertebral dorsal anesthesia. (Pauchet and 
Sourdat.) The needle enters at a point 35 millimeters from 
the median -line, close to the inferior border of the rib ; then, 
at a point 1 centimeter anterior and internal, it reaches the 
nerve root and impregnates the anastomosis with the sym- 
pathetic. 



(a) // blood comes from the needle, a vein 
has been wounded. The position of the needle 
must be changed, otherwise the injection will pass 
into the vein, and no anesthesia will be produced. 
It is important to bear in mind that when this 



THORAX AND ABDOMEN. 149 

accident happens, the patient turns pale and ex- 
periences nausea. 

(/?) Penetration into the plenra will cause 




Fig. 109. — Direction of the lumbar nerves after their emerg- 
ence from the conjugate foramina. (Pauchet.) To reach 
these nerves, the needle is inserted at a distance of 3 centi- 
meters outside of the spinous process. In the case of the in- 
tercostals, at a distance of 3^ centimeters, v^rith the needle 
close to the lower border of the rib, one reaches the nerve 
numbered one less than the spinous process serving as land- 
mark. In the case of the lumbar nerves, the needle, introduced 
at the level of the spinous process, w^ill pass above the upper 
border of the corresponding transverse process and come ia 
contact with the nerve of the same number. 



the patient to cough. The needle should be with- 
drawn and inclined slightly outward. This acci- 
dent, likewise, presents the disadvantage that the 



150 



REGIONAL ANESTHESIA. 



anesthetic is absorbed without producing anesthe- 
sia. To obviate it, one should avoid introducing 
the needle more than i centimeter after having 




' — k— 



Fig. 110. — Paravertebral injection of the dorsal and lumbar 
region, (Pauchet.) The needle enters at a point 3^ centi- 
meters outside of the dorsal spinous process. Reaching the 
lower border of the rib, it then inclines slightly inward, ad- 
vances 1 centimeter, and attains the anastomosis of the sympa- 
thetic, thus anesthetizing the viscera. 



passed the transverse process, or at a distance of 
J^ centimeter below the rib itself. 

For the Lnmhar Xerves. — The needle is intro- 
duced at a distance of 3 centimeters from the 
median line. After the transverse process has 
been found, at a depth of 4 to 5 centimeters, the 



THORAX AND ABDOMEN. 151 

superior border is followed around, the point 
pushed in for another centimeter, and the injec- 
tion made (Figs. 109 and no). 

Dermal infiltration is employed at first, and a 
straight band, corresponding to the roots to be 
injected and parallel with the median line, traced 
on the surface of the skin. The band referred 
to should be traced as follows: 

A very fine, sharp-pointed needle 3 to 5 centi- 
meters in length is used. The skin is marked 
with a dermal pencil at a distance of 3^ centi- 
meters from the median line (it is difficult to 
follow this line exactly without deviation if there 
is no landmark). A strip of skin i centimeter 
wide is now infiltrated with the patient sitting 
bowed forward and the shoulders well drawn in 
as for spinal anesthesia, or lying down on his 
side. 

This having been accomplished, the operator, 
employing a needle 6 or 9 centimeters long — ac- 
cording to its strength — begins injecting the nerves. 
The introduction of the needle will be painless. 
Each spinous process is sought w4th the left in- 
dex finger (a difficult matter in stout people), 
and at the level of the spinous process the needle 
is introduced 3^ centimeters from the median 
line until it meets the rib or transverse process. 
In muscular subjects the inexperienced operator 
must feel his way. When the point strikes the 
rib, it should be withdrawn, then directed against 
and past the lower costal border until the bony 
resistance disappears. The operator now contin- 



152 REGIONAL ANESTHESIA. 

ues to push the needle J^ centimeter beyond and 
injects 5 to 8 mils of the i per cent, solution, at 
the same time executing a to and fro movement 
in order not to miss bathing the nerve. The in- 
jection having been completed, the needle is al- 
lowed to re main in place to serve as a landmark. 
The operator then locates the spinous process of 
the next vertebra below, and at its level and ex- 
actly below the needle above, he introduces his 
second needle and begins as before. For the third 
injection, the second needle is left in place as a 
landmark and, if necessary, the first needle used 
for the injection. 

After the injections are finished about fifteen 
minutes are required for the anesthesia to take 
full effect. The intercostal space, muscles, pleura, 
sternum, and ribs are all rendered insensible. The 
skin anesthesia begins one or two interspaces be- 
low the first injection. Transversely, it occupies 
the intercostal space; anteriorly it reaches the 
median line, and posteriorly, it often stops behind 
the point where the injections have been made. 
If the injections have been practised at points im- 
mediately external to the conjugate foramen, the 
posterior branch is also blocked and a laminectomy 
can be efifected. 

Sixty to 8o grams of the i per cent, solution 
suffice for the anesthetization of 12 nerves. An 
absolute anesthesia of the thoracic wall is thus 
obtained which extends both anteriorly and pos- 
teriorly to the midline. 



THORAX AND ABDOMEN. 153 

For the upper portion of the thorax, the func- 
tions of the cervical plexus must be also inter- 
rupted. A subcutaneous band must be infiltrated 
the length of the clavicle and spine of the scap- 
ula. If the field of operation involves the axilla 
or the supraclavicular fossa, the brachial plexus 
should be anesthetized. 

For thoracic operations invohang only the ribs 
and parietes, there is no objection to substituting 
intercostal anesthesia for the paravertebral anes- 
thesia, i.e., instituting the anesthesia at a more 
lateral point on the course of the intercostal nerve 
above the region to be operated upon. The tech- 
nique of this procedure will be described later. 

PARACENTESIS OF THE PLEURAL CAVITY. 

With a 3-centimeter needle, the course to be 
followed by the trocar passing in from the skin 
to the pleura is injected. A }^ per cent, solution 
proves sufficient; such anesthesia permits of the 
use of large trocars without pain. 

THORACOTOMY FOR EMPYEMA WITH 
COSTAL RESECTION. 

The operator is given the choice between a 
paravertebral anesthesia or the less radical inter- 
costal or pericostal anesthesia, the technique of 
which is as follows : 

Attention is directed to Fig. iii, which rep- 
resents three adjacent ribs. Upon the middle one, 



154 REGIONAL ANESTHESIA. 

the part in black is to be resected; there will 
therefore be two intercostal spaces to anesthetize. 
Four wheals are marked out and through these 
5 mils of the i per cent, solution injected into 
the thickness of the intercostal muscles. The 
needle point seeks the upper rib and follows its 
inferior border until it passes beyond. 




Fig. 111. — Resection of a rib. (Sourdat.) An injection 
is made in the adjacent intercostal spaces forward and back- 
ward on tlie portion of rib to be resected, and followed by- 
peripheral infiltration, subcutaneously and intramuscularly. 



The muscles and subcutaneous tissue are in- 
filtrated with 30 or 40 mils of the 3^ per cent, 
solution in the direction of the arrows. The re- 
sulting anesthesia is complete; yet it is well to 
bear in mind that the patient will complain if any 
traction is made on the ribs, producing torsion of 
the costo-vertebral ligaments. The patient may 
also complain if he hears the section of the ribs; 
it is therefore well to cut the ribs gently and to 
stop the patient's ears. A little girl 11 years of 
age — the niece of a colleague, — upon whom we 
did a resection of 3 ribs for interlobar empyema, 



THORAX AND ABDOMEN. 



155 



cried every time she heard the cutting of a rib, 
though she had not complained once during the 
remainder of the operation, except during the pro- 
duction of the dermal wheals. A man 30 years 
of age cried out when he heard a costal cartilage 
fall into the bucket on the floor. 




Fig. 112. — Resection of the costal cartilages. Diagram of 
the infiltration for mobilization of the ribs, as for emphysema. 
The zone of anesthesia should be extended downward to the 
free border of the ribs if it is desired to remove a section of 
cartilage to be used for filling in a bony gap in the skull from 
trephining. 



RESECTION OF THE SECOND TO THE FIFTH COSTAL 
CARTILAGES FOR RIGIDITY OF THE THORAX. 



From the 2d to the Sth interspace two rows 
of wheals are made (Fig. 112) — the outer at the 
external ends of the cartilages, the inner along 
the sternum. Through each point 5 mils of the 



156 



REGIONAL ANESTHESIA. 




Fig. 113. — Extensive pleurotomy and costal resection for pleu- 
ral sinus. Raising the flap of soft tissues. 



THORAX AND x-\BDOMEN. 



157 




Fig. 114. — Extensive pleurotomy and costal resection for 
pleural sinus. (Pauchet.) The wound tamponed at the close 
of the operation. 



158 PEGIONAL ANESTHESIA. 

I per cent, solution are injected to enclose the 
field of operation in the dotted line, finishing with 
50 mils of the J2 per cent, solution. The same 
procedure is followed for operations involving the 
pericardium and heart, or for subphrenic abscess 
or suppurative costo-chondritis. When decortica- 
tion of the lung is practised for a pleural sinus, 
it should be remembered that in patients who 
have undergone costal resections the ribs have be- 
come welded together. Under these conditions it 
is indispensable to employ paravertebral anesthe- 
sia, intercostal infiltration being* no longer possible. 



Operations upon the Sternum. 

Five mils of the i per cent, solution are in- 
jected on both sides in each space close to the 
sternum. The skin and subcutaneous tissues at a 
distance are then infiltrated with the ^ per cent, 
solution of procaine-adrenin. 



THORACOTOMY FOR ABSCESS OF THE LUNG, EX- 
TRACTION OF FOREIGN BODIES, OPENING OF 
INTERLOBAR ABSCESS, REMOVAL OF 
TUMOR OF THE LUNGS, ETC. 

A very wide anesthesia of the intercostal nerves 
at their origin should be instituted. The operator 
may either employ paravertebral anesthesia or in- 
filtrate the intercostal nerves at points 5 centi- 
meters outside of the line of the spinous proc- 



THORAX AND ABDOMEN. 



159 




Fig. 115. — Wound made for resection of two ribs. (Pauchet.) 
Interlobar pleurisy. 



160^ REGIOXAL ANESTHESIA. 

esses, i.e., at the lateral border of the mass of the 
spinal muscles. The mtercostal spaces are more 
easily found in this situation than elsewhere. 

The operator traces a line with a dermal 
pencil at a distance of 5 centimeters from the 
spinous processes. Then, with a very fine and 
sharp needle 6 centimeters long, a band i centi- 
meter wide is infiltrated with the ^ per cent, 
solution along this line, with the patient sitting 
down, bent forward, and with the shoulders 
drawn inward; or lying down on the side. Along 
this line and on a level with each spinous process, 
an injection is made immediately below the cor- 
responding rib. Paravertebral anesthesia, which 
renders the lung insensitive, is the procedure of 
choice. 



Operatioxs for Tumor of the Breast. 

For benign operations on the breast, including 
extirpation of adenoma and total extirpation of 
the mammary gland, a large subcutaneous lozenge, is 
circumscribed through 4 or 5 wheals. Next, the sub- 
mammary tissue is infiltrated, thus completing an 
absolute circumferential anesthesia. A large amount 
of ^ per cent, solution — 100 or 150 mils — is re- 
quired. Half of the liquid runs ofif w4th the 
blood during the operation. AA> have injected as 
much as 250 mils without any harmful after-eitects. 



THORAX AND ABDOMEN. 161 



REMOVAL OF CANCER OF THE BREAST. 

Procaine-adrenin has been used by us several 
times for this purpose, not only in thin women, 
but also in fat women w^th some contraindication 
to general anesthesia, such as renal insufficiency, 
myocarditis, etc. The results were good. At times 
inhalation of ethyl chloride became necessary, how^- 
ever, at the time of dissection of the axilla. 

The technique comprises the following steps: 

(a) Blocking of the brachial plexus with lo mils 
of the I per cent, solution, injected from above 
the clavicle or in the axilla. The latter route 
presents the added advantage of anesthetizing 
simultaneously the surrounding cellular tissues. 

(b) Paravertebral injection from D. i to D. lo 
with 50 mils of i per cent, solution. (c) Sub- 
cutaneous injection of ico mils of ^ per cent, 
procaine-adrenin, starting at the acromion, follow- 
ing the claA^cle to block the cervical plexus, then 
the midline of the thorax, the lower border of the 
thorax, and finally passing backw^ard to the promi- 
nence of the latissimus dorsi. In the case of an 
obese woman, we employ ordinarily 150 mils of 
procaine-adrenin; large amounts of the fluid run 
off, however, during the operation. By the use 
of hypotonic saline solution the dose of procaine- 
adrenin injected may be reduced. 



11 



162 REGIONAL ANESTHESIA. 



Operations in the Axilla. 

Theoretically, the brachial plexus may be blocked 
by supraclavicular injection and the first 5 inter- 
costal nerves by paravertebral injection. To the 
inexperienced operator we advise, however, merely 
an infiltration of the axilla, as explained later. 



ABDOMEN. 

If the operative procedure required consists 
merely of incising an anterior peritoneal abscess, 
appendicular or otherwise, simple infiltration of 
the wall by Reclus's method is sufficient. For an 
operation involving prolonged maneuvers, such as 
exploration of the abdomen, recourse must be had 
to anesthesia of the wall at a distance and to 
paravertebral anesthesia. 

(A) Infiltration of the wall at a distance from 
the field of operation results in a block of the 
nerve supply and yields a perfect anesthesia, but 
one which is only parietal. While the viscera are 
not reached, the incision, separation, and suture of 
the abdominal wall are rendered painless. The 
viscera, furthermore, are only slightly sensitive pro- 
vided no traction be exerted. This semi-sensibil- 
ity on their part permits of the performance of 
gastro-enterostomies and intestinal resections under 
parietal infiltration, without shock. 

In some instances, after the abdomen has been 
opened, the anesthesia can be continued by direct 



THORAX AND ABDOMEN. 163 

injection of quinine and urea solution into the 
mesentery. One mil of a i per cent, solution may 
be injected into the meso-appendix for appendicec- 
tomy, and a few drops of a i per cent, solution 
in the vicinity of each omental vessel for resection 
of the omentum. Such injections between the two 
layers of the peritoneum, along the vessels, gives 
a perfect anesthesia; but it is only practicable in 
certain special cases. For resection of the stom- 
ach, for instance, we anesthetize the nerves of 
the organ by infiltrating the peritoneum in the 
vicinity of the coronary artery, the pylorus, and 
the two gastric omenta. Only very gentle handling is, 
however, permissible, or during painful manipula- 
tions some drops of ethyl chloride, chloroform, or 
ether will have to be administered. The anesthe- 
sia is often incomplete, demanding either some 
mental encouragement of the patient or a few 
whiffs of an anesthetic. In three-fourths of the 
cases this method proves effective, and permits of 
the performance of severe operations without 
shock. 

(B) Paravertebral anesthesia^ on the other hand, 
gives absolute anesthesia, at least on the side of 
the body on which it is made. It must be bi- 
lateral if the viscera are in or pass beyond the 
median line. A choledochotomy, or removal of a 
tumor of the cecum, can be perfectly performed 
under right-sided paravertebral anesthesia. For a 
nephrectomy, or the removal of a circumscribed 
tumor of the colon, unilateral anesthesia is like- 
wise sufficient. To operate on the stomach (gas- 



164 REGIONAL ANESTHESIA. 

trectomy) or pancreas, however, both sides must 
be injected. 

The operator may manipulate throughout the 
abdomen by infihrating from the Sth intercostal 
to the 2d lumbar nerve on both sides. The re- 
quired 22 injections are, however, distressing and 
involve the use of a large dose of procaine- 
adrenin. 

On several occasions we have made a trans- 
verse bilateral incision after paravertebral infiltra- 
tion of only 6 nerves on each side; the anesthe- 
sia was perfect. For the stomach, we do not em- 
ploy this procedure systematically because we pre- 
fer the long vertical incision, and we confine the 
anesthesia to simple infiltration of the abdominal 
wall with injection of quinine and urea in the 
mesentery. The two forms of anesthesia may be 
combined by (a) making a double paravertebral 
injection of the D. 6, /, 8, and 9 nerves, — 8 in- 
jections all told, 4 on each side — to anesthetize 
the stomach and epigastric wall, and (&) infiltrat- 
ing in the midline below the umbilicus for a dis- 
tance of 5 to 6 centimeters with a weak anes- 
thetic solution. 

Practice with paravertebral injections induces 
the surgeon to employ them more and more fre- 
quently in his work, as they are particularly 
adapted for abdominal surgery. The more experi- 
enced the surgeon in the technique, the more in- 
clined he becomes to substitute the procedure for 
parietal infiltration. I shall present, however, with 
reference to each operation, the details of the 



THORAX AND ABDOMEN. 



165 



latter, pointing out at the same time the precau- 
tions to be taken during the course of the opera- 
tion under regional anesthesia. 



Operations upon the Stomach, 
gastrostomy and gastro-enterostomy. 

Three dermal wheals are infiltrated, — one at 
the level of the ensiform cartilage, the others at 




Fig. n6. — Infiltration for supraumbilical laparotomy. Six 
wheals. For gastrectomy and gastroenterostomy. 



the free borders of the ribs lo or 12 centimeters 
from the first. The subcutaneous cellular tissues 
and portions of muscle attached to the costal border 
are infiltrated successively in order to block the 



166 REGIONAL ANESTHESIA. 

nerve filaments that supply the midline over two- 
thirds of its length above the umbilicus. The ab- 
dominal wall can then be immediately incised, 
either to the right or left of this line. Next, the 
skin and muscles over the free borders of the ribs 
on the left side are infiltrated for a distance of 
10, 12, or IS centimeters. 

Manipulations of the stomach being but slightly 
painful, all complementary anesthesia is useless. 
The infiltration requires from lOO to 120 mils of 
the weak solution to completely relax the abdom- 
inal muscles. Such anesthesia is sufficient also for 
gastro-enterostomy. We inject previously, how- 
ever, pantopon or scopolamine-morphine. 



GASTRECTOMY. 

The same paracostal incision is made, but in a 
bilateral form (Fig. 117). The operation is rather 
more painful owing to the extensive and pro- 
longed manipulation of the stomach involved. If 
a complete anesthesia is considered advisable, it 
is necessary either to institute a double paraver- 
tebral anesthesia (6 nerves on each side) or after 
the abdomen is opened to give some whiffs of 
chloroform or infiltrate the mesentery with qui- 
nine and urea. It will be sufficient to chloroform 
the patient slightly during the liberation and ex- 
ploration. The suturing and cutting of the intes- 
tines are painless. The mental condition of the 



THORAX AND ABDOMEN. 



167 



patient is all-important. There are great contrasts 
between individual temperaments. Some patients do 
not utter a word during the operation, while others 
cry out for an anesthetic and never cease com- 
plaining. 



/ 




5 2 \ |S 




Fig. 117. — Infiltration for high laparotomy. (Sourdat.) 
Yields a larger area of anesthesia than the preceding. For 
gastro-enterostomy; operations on the gall-bladder and colon. 



Median Hypogastric Incision. 

We seldom practice abdomino-pelvic operations 
under local anesthesia. Yet the evacuation of a 
tuberculous ascites or the removal of a movable 
tumor of the ovary may be very easily effected 
with this procedure. The pedicle should be in- 
filtrated with a I per cent, solution of quinine and 



168 REGIONAL ANESTHESIA. 

urea without injecting the viscera; it can then 
be easily crushed and tied without pain. 

Cesarean section can readily be practised under 
infiltration anesthesia. A lozenge-shaped area 
three finger-breadths wide, in the median line, is 
infiltrated so as to block the musculo-cutaneous 
endings of the abdominal nerves. Opening of the 
abdomen is thus rendered painless, the peritoneum 
having been anesthetized by the blocking of the 
parietal nerves. The uterus is almost insensitive; 
yet it is well to anesthetize it with quinine and 
urea, infiltrating a strip of uterine tissue on each 
side of the intended uterine section at a distance 
of two or three finger-breadths from the median 
line. There is little bleeding. 

In hysterectomy, as for cancer, fibroids, or sal- 
pingitis, we prefer lumbar spinal anesthesia, but 
bilateral paravertebral anesthesia will also serve 
the purpose. One must inject twelve pairs on 
each side, — the six lower intercostals, three lum- 
bar, and three sacral. For the lesser operations, 
such as hysteropexy, removal of ovarian cysts, 
etc., we prefer a brief general anesthesia. 

Hypogastric anesthesia for cystotomy is insti- 
tuted through two wheals, the one at the umbili- 
cus and the other at the pubis. Through these 
one infiltrates, not in the median line, but on 
either side, the skin and muscles. The peritoneum 
is itself anesthetized. The muscles must be anes- 
thetized, and not the linea alba, — that they may be 
separated without pain. 



THORAX AND ABDOMEN. 



169 



Operations in the Iliac Fossa, 
ileocecal region. 

Here it is well to institute a sufficiently low 
paravertebral anesthesia, i.e.^ one involving the 
last two intercostal nerves and the first three lum- 
bar. If, owing to the technical difficulties, the 
operator prefers to block the nerves nearer the 




y^ 

{ 









I 



I 



# 



•/ 



li 



Fig. 118. — Infiltration for operative work in the ileocecal 
region. (Paiichet.) A diamond-shaped figure under the skin 
and in the muscles, circumscribing the future incision, should 
be infiltrated. For appendicitis ; ileocecal resection. 



field of operation, he can have recourse to infiltra- 
tion of the abdominal wall in the following man- 
ner (see Fig. Ii8 and the subsequent illustrations). 

Four dermal w^heals are made, in the form 
of a lozenge. The two lateral wheals are placed, 
the one inside the anterior superior spine of the 
ilium, the other, two or three finger-breadths from 



170 



REGIONAL ANESTHESIA. 



the middle line. The superior and inferior wheals 
are situated, the one at a distance of three finger- 
breadths from the first, the other, three finger- 
breadths from the second. The muscular layers 
should be infiltrated only at the two upper sides 
of the lozenge; over the two lower sides only the 




Fig. 119. — Deep "fan-shaped" injection to infiltrate the mus- 
cular mass at the point of emergence of the nerves of the in- 
guino-crural region. (Pauchet.) (D) Rectus abdominis. (B) 
Ilio-psoas. (A) GUiteus. (C) Iliac bone. (E) Three direc- 
tions of the needle: the first perpendicular to the skin, toward 
the subserous cellular tissue; the second, parallel to the skin, 
beneath the aponeurosis ; the third, intermedia::e, oblique in the 
intermuscular space, where the nerves are found. (1) Dermal 
wheal. 



subcutaneous cellular tissue is to be infiltrated. 
The infiltration of the muscles produces not only 
anesthesia of these structures, but also anesthesia 
of the peritoneum. 

With this procedure we have performed the 
following operations: Cecostomy, resection of the 
ileocecal segment for cancer or tuberculosis, ap- 
pendicectomy, closing of intestinal fistula, and en- 
terostomy. 



THORAX AND ABDOMEN. 



171 



The incision in the abdominal wall and the 
separation of the wound margins are painless, but 
it is necessary to infiltrate the meso-appendix or 
the end of the mesentery with quinine and urea 
if section of this last structure is indicated. 




Fig. 120. — Same as the preceding. (Pauchet.) Horizontal 
section at the level of the iliac spine. (1) Rectus abdominis. 
(2) and (3) Ilio-hypogastric and ilio-inguinal nerves, situated 
at this point between the internal oblique and transversalis 
muscles. (4) Genito-crural nerve. (5) Iliac bone. (6) 
Parietal peritoneum. (E) Wheal situated two finger-breadthc 
within the iliac spine and through which the fan-shaped injec- 
tion is made. 



On the whole, I desire to emphasize the fact 
that paravertebral anesthesia for the viscera is 
rather to be recommended. The operation for ap- 
pendicitis may almost always be performed under 
it. We have operated upon children of 8 years, 
and with greater facility children of lo to 15 
years, without general anesthesia. 



172 



REGIONAL ANESTHESIA. 




Fig. 121. — Deep, "fan-shaped" injection above the anterior 
superior iliac spine. (Pauchct and Sourdat.) To anesthetize 
the wall of the iliac fossa, for appendectomy, cecostomy, ileo- 
cecal resection. The figure shows the manner of direct injec- 
tion, perpendicular to the plane of the wall. 



THORAX AND ABDOMEN. 



173 




Fig. 122. — Oblique injection upward. (Paiichet and Sourdat.) 
Note the direction imparted to the syringe and needle. 



174 



REGIONAL ANESTHESIA. 




Fig. 123. — Same injection directed obliquely downward. 
(Pauchet and Sourdat.) 



THORAX AND ABDOMEN. 



175 




IliD-inguinal 
Ilin-hyp agastric 

: GEnitn-crural 



Fig. 124. — Paracostal anesthesia — costo-iliac and para-ijiac. (Pau- 
chei.) Anesthesia of the entire abdominal wall (anesthetized zone in 
gray) , To the right are seen the intercostal filaments supplying the 
abdominal wall, and lower down the ilio-hypogastric and ilio-inguinal 
nerves, and the genito-crural (vertically directed). To the left of the 
figure, A, B, and C show the paracostal infiltration of a portion of 
muscle and of the skin (stomach, liver, and duodenum). C, D, anes- 
thesia of the abdominal wall for the ascending colon. E. F. useful for 
cecal or appendicular operations and for the radical cure of inguinal 
hernia. 



176 



REGIONAL ANESTHESIA. 




Fig. 125. — Appendicitis. (Pauchet and Sourdat) 
of the abdominal wall. 



Incision 



THORAX AND ABDOMEN. 



1?7 




Fig. 126. — Appendicitis. (Pauchet and Sourdat.) The ap- 
pendix and cecum are brought to the exterior. 



12 



178 



REGIONAL ANESTHESIA. 




Fig, 127. — x\nesthesia of the meso-appendix. (Pauchet.) 
Interval operation. The needle is inserted between the two 
layers of the meso-appendix, in the vicinity of the appendicular 
artery. One mil of J/4 per cent, quinine and urea hydrochloride 
solution is injected. The operator may then tie and divide, 
without pain, the meso-appendix and the appendix itself. 



THORAX AND ABDOMEN. 



179 




Fig. 128. — Quinine and urea anesthesia of the mesenteric 
nerves before intestinal resection. (Pauchet.) The needle is 
inserted in the first layer of the mesentery, and 1 or 2>^ mils 
of ^ per cent, quinine and urea solution injected. The oper- 
ator is enabled immediately to cut the vascular pedicle and re- 
sect the intestine without pain. In this instance, it is the 
transverse colon. 



180 



REGIONAL ANESTHESIA. 




Fig. 129. — Pylorectomy for callous ulcer. (Pauchet.) First 
step: Exploration of the abdomen. (Patient from the La Pitie 
Hospital). 



THORAX AND ABDOMEN. 



181 




Fig. 130. — Pylorectomy for callous ulcer. (Pauchet.) Pyloric seg- 
ment resected. The canal has been incised lengthwise along the greater 
curvature, then spread out. Lower down, the great omentum is seen 
attached to the greater curvature by an inflamed lymph-gland. The 
operative mortality is 8 per cent. 



182 



REGIONAL ANESTHESIA. 




Fig-. 131. — Continent jejunostomy. (Pauchef.) For a large 
cancer of the stomach. (Patient from La Pitie Hospital). 




Fig. 132. — Artificial anus due to wound of the intestine. 
(Pauchet.) Military wound from La Pitie Hospital (shell 
splinter). Circular enterorrhaphy. 



THORAX AND ABDOMEN. 



183 




Fig. 133. — Ileocecal segment invaded by cicatricial tuberculosis. 
(Pauchet.) To the right the end of the small intestine may be recog- 
nized. The cecum has become transformed into a fibrous mass, with 
a small, hardly perceptible, mucous canal. (La Pitie Hospital.) 



184 



REGIOXAL ANESTHESIA. 




Fig. 134. — Partial gastrectomy for saddle ulcer of the lesser curva- 
ture. (Pauchet.) First stage of the operation : Separation of the 
omentum by means of the scalpel. The assistant holds the transverse 
colon with the left hand; the operator holds the scalpel with his right 
hand and with the left the omentum is separated from the transverse 
colon for examination of the posterior surface of the stomach. Mor- 
tality 8 per cent. 



THORAX AND ABDOMEN. 



185 




Fig. 135. — Specimen from the preceding patient, (Pauchet.) Mid- 
dle segment of the stomach, showing a saddle ulcer of the lesser curva- 
ture. The resected segment has been laid open along the greater 
curvature, to which the omentum is attached below. The center of the 
figure, where the ulcer is found, corresponds to the middle of the 
lesser curvature. 



186 



REGIONAL ANESTHESIA. 



Umbilical Hernia. 

Umbilical hernias and hernias of the linea alba 
are operated under lateral infiltration of the mus- 
cles, in the same manner as for laparotomy. The 
operator infiltrates successively the skin and the 




Fig. 136. — Anesthesia for radical cure of a reducible um- 
bilical hernia. (Pauchet.) Through the wheals a ring of in- 
filtration is made, following the dotted line, under the skin 
and in the thickness of the muscles. 



muscles down to the subserous cellular tissue with 
a weak solution. Pauchet, in 19 14, operated at 
Amiens on an obese woman with a strangulated 
hernia in the median line, of the size of an adult's 
head and containing 1.50 meters of gangrenous 
intestine. The patient complained somewhat whe.n 



THORAX AND ABDOMEN, 



187 



the mesentery was ligated, but it did not become 
necessary to have her inhale any chloroform. Two 
hundred and fifty mils of a ^ per cent, solution 
were employed. 

In an extremely obese woman with a simple 
umbilical hernia, Pauchet injected as much as 300 




Fig. 137. — Location of the wheals and the proper direction 
of injection for anesthetization in irreducible umbilical hernia. 
{Pauchet.) 



mils of the weak solution. Part of the fluid es- 
caped, how^ever, during the operation. In making 
these injections, 12-centimeter needles were em- 
ployed. 

For all these operations, the procedure is al- 
ways the same. A lozenge-shaped wall of infil- 
tration around the umbilicus is established. Through 
four wheals all of the subcutaneous tissue and 



188 REGIONAL ANESTHESIA. 

muscles are infiltrated, following the lines that 
form the lozenge. In cases of umbilical hernia 
and post-operative eventration, injection of quinine 
and urea into the omentum, about the vessels, is 




Fig. 138. — Injection for irreducible umbilical hernia. 
(Pauchet.) The infiltration is conducted at a distance from 
the ring and through the entire thickness of the wall. 



an important preliminary to resection of the omen- 
tal membrane, which under this treatment becomes 
absolutely insensitive. 



Inguinal Hernia. 

The operation for inguinal hernia is without 
doubt, of all operations, that in which regional 
anesthesia gives the greatest satisfaction, no mat- 
ter how voluminous the hernia may be. That it 
is indicated is due to three factors: (i) The 
disease itself is hardly more dangerous than gen- 
eral anesthesia; the latter may give rise to a bron- 
chitis that is prejudicial to consolidation at the 



THORAX AND ABDOMEN. 



189 



points of suture; (2) the resultant vomiting has 
the same tendency; (3) regional anesthesia, which, 
it must be recognized, is imperfect for certain 
operations, shows its utility for the radical cure 




Fig. 139. — Nerve supply of the inguinal region (diagram- 
matic). (Pauchet.) Points of emergence of the genito-crural, 
ilio-hypogastric, ilio-inguinal, and of an anterior branch of the 
12th intercostal. For anesthesia of the inguino-crural region 
they should be reached here by injection. The needle should 
be introduced within the anterior superior iliac spine. 



of inguinal hernia when properly employed, and 
the technique for this operation is very simple. 
In April, 19 16, at the La Pitie Hospital we op- 
erated on an inguinal hernia of the size of a 
large adult's head, without the slightest pain. 



190 REGIONAL ANESTHESIA. 

Paravertebral anesthesia will yield a perfect 
anesthesia at a distance and seems to us the pro- 
cedure of election. No matter how large the her- 
nia, it will be sufficient to inject the two lower 
intercostal and upper three or four lumbar nerves. 
Yet the great majority of surgeons prefer anes- 
thesia by localized infiltration of the nerves of 
the region, the technique of which is as follows : 

Figures 139 and 124 show the innervation of 
the groin and of the crural region respectively. 
The genital branch of the genito-crural reaches 
the spermatic cord through the internal ring and 
accompanies it in the canal and in the skin of 
the scrotum or of the labia major a. The ilio-in- 
guinal is situated above the iliac spine, between 
the oblique muscles; it passes under the aponeu- 
rosis of the external oblique, emerges from the 
inguinal canal upon the anterior surface of the 
cord and of the sac, and ends in the skin of the 
scrotum or mons veneris. The ilio-hypogastric, 
parallel to the preceding and slightly higher up, 
makes its way between the two oblique muscles; 
reaching the inguinal region, it passes under the 
aponeurosis of the external oblique, crosses through 
the anterior layer of the sheath of the rectus, and 
ends in the skin of the groin. These three nerves 
anastomose with each other. It is necessary, 
therefore, that all three be anesthetized. They are 
all to be found grouped together in a space of 2 
or 3 finger-breadths within and above the iliac 
spine. 



THORAX AND ABDOMEN. 



191 



REDUCIBLE INGUINAL HERNIA. 

Two wheals are made, the first two finger- 
breadths within the anterior superior ihac spine 
and the second corresponding to the pubis at the 




Fig. 140. — Anesthesia for irreducible inguinal hernia. 
(Sourdat.) Location of the two wheals. The arrows show 
the direction of the deep injections. The unbroken line out- 
lines the subcutaneous infiltration. 



level of the external abdominal ring. Through 
wheal No. i, infiltration is executed according to 
the scheme shown by the arrows in Figs. 119 
and 120. All the muscular layers situated be- 
tween point I and the ilium are infiltrated, using 



192 



REGIONAL ANESTHESIA. 




Fig. 141. — Same as the preceding. (Sourdat.) A wheal 
is made two finger-breadths within the anterior superior iliac 
spine. The second wheal is made above the horizontal ramus 
of the pubis. The black line shows the subcutaneous infil- 
tration. 



THORAX AND ABDOMEN. 193 

20 mils of a I per cent, solution. A 9-centimeter 
needle is introduced perpendicularly, passing through 
the aponeurosis of the external oblique, the inter- 
nal oblique, and the transversalis muscle. It is 
then inserted so as to cover a fan-shaped sector, 
and more and more obliquely toward the spine 
of the ilium. The muscular layer here is very 
thick. This injection reaches the ilio-hypogastric 
and ilio-inguinal nerves. Through point i, it is 
necessary to infiltrate anew under the aponeurosis 
of the external oblique a strip ending at two 
points situated, respectively, within and externally 
to the hernial ring, using approximately 20 mils of 
the weak solution. Through wheal No. 2, 10 mils 
of the solution are injected in a fan-shaped area 
to the line of the cord; the needle should strike 
the pubic bone. Through the same point, 10 mils 
are next injected in the inguinal canal itself 
along the cord. Finally, subcutaneous infiltration 
is conducted following the lozenge-shaped figure 
shown in the illustration, approximately 100 mils 
of the weak solution — ^ per cent. — being used 
altogether (Figs. 140 and 141). 



IRREDUCIBLE OR STRANGULATED INGUINAL 
HERNIA. 

Four w^heals are made as indicated in Fig. 
142. Through wheal No. i one injects, as before, 
against the iliac bone, and continues toward 
wheals Nos. 2 and 3, injecting under the aponeu- 

13 



194 



REGIONAL ANESTHESIA. 



rosis. Next, two deep injections are made through 
points 2 and 3. While the left hand pushes 
laterally inward and outward the hernia mass, the 
needle is inserted as far as the pubis, under the 




Fig. 142. — Lines of infiltration for inguinal hernia. (Sourdat.) 
For irreducible or strangulated hernia. 



hernia, and injection made deeply in the canal 
through points 2 and 3 along the neck of the 
sac. Finalh^, a subcutaneous injection between the 
points 1-2-3 and 2-3-4, is made. For a large 
hernia 150 mils of the weak solution may be used. 



THORAX AND ABDOMEN. 



195 



We prefer in such cases the paravertebral form of 
anesthesia, which deals with the nerves supplying 
the cord. The procedure just described, however, 
will likewise give satisfaction (Figs. 142 and 143). 




Fig. 143. — Anesthesia of the scrotum for irreducible her- 
nia. (Sourdat.) Subcutaneous infiltration of the root of the 
scrotum through a crown of wheals. 



Femoral Hernia. 

The nerve supply in femoral hernias is essen- 
tially that of the inguinal region. The anesthetic 
procedure, therefore, is almost the same: 



196 



REGIONAL ANESTHESIA. 



Four dermal wheals are made. Point i occu- 
pies the same place as in inguinal hernia, viz., 
two finger-breadths within the anterior superior 
iliac spine. Points 2 and 3 are within and out- 




Fig. 144. — Reducible femoral hernia. The deep injections 
(arrows) and subcutaneous circuminfiltration are made through 
wheals 1, 2, 3, and 4. 



side of the hernia, respectively, and at both ends 
of the intended femoral incision, parallel to the 
femoral arch. Point 4 is below the hernial mass. 
One starts with the intramuscular injections at 
point I. Through this one injects under the 
aponeurosis up to and outside of the neck. Then, 



THORAX AND ABDOMEN. 



197 




Fig. 145. — Irreducible femoral hernia. (Pauchet.) A fan- 
shaped intramuscular injection is made through point A, 
Infiltration of a subcutaneous band surrounding the hernial 
tumor and neck is conducted through points A, B, C, and D. 

I 




f 



Fig. 146. — Anesthesia of the hernial sac and testicle by- 
infiltration of the cord. Injection of the cord in the inguinal 
canal. 



198 REGIONAL ANESTHESIA, 

under the femoral arch through point 4, 10 mils 
of the solution are infiltrated around the neck, and 
very close to it. Finally, subcutaneous infiltration 
is effected. The femoral arch is anesthetized by 
this procedure. If it be necessary to combine an 
inguinal incision with the high femoral incision, 
the anesthesia will be sufficient for the purpose. 
We have never been compelled to give ethyl chlo- 
ride to the patient during the liberation of the 
intestine. When, however, in a stout patient, we 
contemplated radical cure of a femoral hernia 
through the inguinal route, the patient complained 
somewhat while we were working deeply, showing 
that the anesthesia had been incorrectly instituted. 

Operations upon the Kidney. 

Nephrectomy is another operation for which 
regional anesthesia is indicated. This method 
saves the renal tissue in the same way as it does 
the hepatic. The anesthesia, moreover, is com- 
plete. The lateral position of the subject can be 
maintained without the help of an assistant, the 
patient's voluntary aid being sufficient. Decortica- 
tion of the kidney and the ligation of the pedicle 
are painless. We employ unilateral paravertebral 
injection of the six lower intercostal and of two 
lumbar nerves. When once familiar with the 
technique, one no longer finds it necessary to 
have the patient inhale any additional anesthetic 
at the time of decortication of the kidney. 



THORAX AND ABDOMEN. 199 



Operations upon the Biliary Passages. 

It is advantageous to perform these without 
ether or chloroform, the harmful action of which 
upon the hepatic cells is well known. Our first 
operations under paravertebral anesthesia were 
done upon patients suffering from chronic jaun- 
dice, — of two months' standing in one instance 
(pancreatic tumor) and in another, six months (for- 
mer lithiasis, with acute obstruction of the ductus 
choledochus). The post-operative course was de- 
void of complications, and the operations were ab- 
solutely painless, even in the second case, ren- 
dered difficult by multiple, long-standing adhesions. 
Since then all of our hepatic and biliary opera- 
tions have been conducted under paravertebral 
anesthesia. 

Right-sided paravertebral infiltration of the six 
lower intercostals and first two lumbar are re- 
quired for the purpose. Here, as in the case of 
the kidney and other similar operations, one is 
struck by the frequent diinimition of post-opera- 
tive pain in the succeeding twenty-four hours. 
The method allow^s of the performance of chole- 
cystectomy. Vertical or transverse incisions may 
be employed provided they do not cross the median 
line. The cushion placed under the chest may be 
a cause of suffering, which is obviated by a pre- 
vious injection of morphine. 



CHAPTER VI. 

ANESTHESIA OF THE GENITO-URINARY 
ORGANS AND RECTUM. 

The pelvic organs and external genitalia are 
supplied by the internal pudic nerve, the small 
sciatic, and the sacral and coccygeal plexuses, which 
anastomose with branches from the pelvic sympa- 
thetic. 




Fig. 147. — Nerve supply of the perineum in the male. 
(Pauchet.) Trunk of the internal pudic nerve and branches 
of the small sciatic. 



The internal pudic nerve emerges from the 

pelvis through the great sciatic notch, winds around 

the external surface of the sciatic spine, traverses 

the ischio-rectal fossa, and gives filaments to the 

(200) 



GENITO-URINARY ORGANS AND RECTUM. 



201 




Fig. 148. — Nerve supply of the perineum in the female. 
(Pauchet.) Internal pudic nerve and branches of the small 
sciatic. 




Fig, 149. — Sensory segments of the perineum correspond- 
ing to the last spinal pair. (Pauchet.) The branches 6^ indi- 
cate the sacral nerves, with the number of the foramen of 
emergence. The branches L are lumbar. The number is that 
of the corresponding segment. (See also Figs. 220 and 221.) 



-202 REGIONAL ANESTHESIA. 

skin of the perineum, anus, posterior half of the 
scrotum, penis, and vulva. The anterior half of 
the scrotum and of the labia majora is supplied 
by the genito-crural and the ilio-inguinal. The 



Fig. 150. — Pre-sacral anesthesia. (Pauchet.) To reach all 
sacral foramina but the first, the needle is introduced between 
the anus and coccyx and follows the anterior surface of the 
sacrum to each foramen. To reach the first sacral foramen, 
the needle is inserted at the same point but is pushed directly- 
through the tissues to reach the sacral brim When the bone 
has been reached, the injection is made. 



2(1, 3d and 4th sacral pairs constitute the hypo- 
gastric plexus, and through it supply the bladder, 
prostate, uterus, rectum, and pelvic peritoneum. 

Regional anesthesia for the above operations is 
simple and easy of application, and the various 
regions involved and methods of treatment are 



GEXITO-URIXARY ORGAxXS AND RECTUM. 



203 




Fig. 151. — Trans-sacral anesthesia. (Pauchet.) Note the 
depth to which the needle B penetrates to reach the pos- 
terior foramen Si. On the contrary B finds the orifice 
Sj immediately beneath the skin. The needle penetrates ap- 
proximately 25 millimeters to reach the first sacral foramen, 
20 for the second, 15 for the third, and 10 for the fourth, and 
should be driven about 1 centimeter into each canal in order 
to reach the anterior as well as the posterior division of the 
nerve. It is well to introduce the index finger into the rectum 
in order to be certain that the point of the needle is not pene- 
trating the rectal wall. 



204 



REGIONAL ANESTHESIA. 




Fig. 152. — Pre-sacral and trans-sacral anesthesia. (Pauchet.) 
The first of these procedures is indicated in the obese and the 
second in thin subjects. In the latter the bony landmarks are 
more easily found. Note the direction followed by the pre- 
sacral needle for each foramen. The first four anterior arrows 
reach the foramina 5, 4, 3, and 2. The needle point should be 
kept in constant contact with the concavity of the sacrum, and 
should always be parallel to the middle line of this bone. The 
arrow destined for Si aims directly at the superior strait of 
the pelvis. As soon as it comes in contact with this, the needle 
is at the sacral foramen Si. If injury of the rectum is appre- 
hended, a finger should be inserted in it during the introduc- 
tion of the needle. 



GEXITO-URIXARY ORGANS AND RECTUM. 205 

fully shown in Figs. 147 to 158. In Fig. 152 are 
shown the two methods of application. In thin 
subjects the injections are made through the five 
sacral foramina. In stout subjects it is often 
easier to reach the sacral nerves by introducing 
the needle at a point between the rectum and the 
tip of the coccyx, and infiltrating the concavity of 
the sacrum with a i per cent, solution of pro- 
caine-adrenin. 

Anterior Sacral (Pre-sacral) Anesthesia. 

The patient is placed in the dorsal position, 
with the thighs flexed upon the abdomen. After 
proper preparation of the skin w4th iodine and 
alcohol, an intra-dermal wheal is formed at a 
point midway between the anus and the tip of the 
coccyx, thus permitting the introduction of the suc- 
cessive needles without pain. 

Through the wheal thus formed a needle 9 
centimeters long is introduced and with its point 
the inferior and outer border of the sacrum about 
2 centimeters from the median line is found. The 
needle is now pushed forward, with its point in 
constant contact with the anterior face of the 
sacrum, for about i centimeter, which should 
bring the point to a level with the fifth sacral 
foramen. Five mils of a i per cent, solution are 
thereupon injected. 

One then continues upward, parallel and at 
about 2 centimeters from the median line, keeping 
the needle point constantly in contact with the sur- 



206 REGIONAL ANESTHESIA. 

face of the bone, at a distance of about i^ to 
2 centimeters from the point already injected, 
when it should be at the level of the fourth sac- 
ral foramen. Here again 5 mils of i per cent, 
solution are injected. Then, with the needle in 
contact with the bone and always about 2 centi- 
meters from the median line, one proceeds about 
lyi to 2 centimeters higher up to the third fora- 
men, where 5 mils should again be injected. In 
the same manner the needle is pushed upward a 
fourth time to the second foramen, where the 
same amount of solution is again injected. The 
needle is next drawn back to the starting point 
and the same manipulation repeated on the oppo- 
site side of the median line, thus bringing under 
control both sets of nerves. 

The first needle is now replaced by one 12 
centimeters long, the gloved finger placed in the 
rectum, and the needle introduced at the same 
point. Instead of following the surface of the 
bone, however, one next pierces directly upward 
to a depth of 9 to 10 centimeters, and with the 
finger in the rectum aiding as a guide, aims to 
strike the upper part of the sacrum as it tilts 
forward. At this depth, about 2j4 centimeters 
from the median line and against the bone, the 
first sacral foramen is attained. Five mils of solu- 
tion are injected and the procedure repeated on 
the opposite side. The last injection is an extra 
precaution. As a rule it is not needed, complete 
anesthesia of the parts being secured by injection 
of the other four pairs. 



GExNITO-URINARY ORGANS AND RECTUM. 



207 



Anesthesia Through the Sacral Foramina — 
Trans-sacral Anesthesia. 

The patient is placed in the extended posture 
and face down upon the table. With the aid of 



I' 




Fig. 153. — Location of the posterior sacral foramina. 
(Pauchet.) MM', middle line of the body. V, spinous proc- 
ess of the 5th Imnbar vertebra. /-/' lines joining the iliac 
crests. TV, postero-inferior spines of the ilia. H, fourth 
sacral spinous process. CC, sacral cornua. X, sacral hiatus. 

a dermographic pencil, a line is drawn from the 
crest of one ilium to that of the other (Fig. 
156, CC). The relationship of the posterior supe- 
rior spines of the ilia is shown at EE. The 
sacral cornua, BB, are now found and marked. 
From top to bottom a line is drawn directly over 



208 



REGIONAL ANESTHESIA. 



the median line from D to A. A point 4 centi- 
meters on each side from the median Hne, on the 
line CC, is marked. This point is connected on 




Fig. 154. — Posterior surface of the sacrum, showing the 
posterior sacral foramina and sacral nerves. (Pauchet.) A, 
the interiliac line. B, line joining the two postero-inferior 
iliac spines. M, line joining the two middle spinous processes. 
C, horizontal line passing through the two sacra) cornua at 
the level of the sacral foramen, S5. The oblique line corres- 
ponds to the situation of the sacral foramina ; it is located 
25 millimeters from the middle line at the level of the two sac- 
ral cornua. Note that the lumbo-sacral space, through which 
spinal anesthesia may be induced (Le Filliatre) is at the mid- 
dle of the interval that separates A from B. K, point cor- 
responding to the fourth sacral spinous process. S4 is situated 
1 centimeter outside of K. 



each side by a Hne drawn downward to the 
point B. The hne passes directly over the ^yq 
sacral foramina. Commencing at the top, the first 
foramen is found on this line directly opposite the 



GENITO-URINARY ORGANS AND RECTUM 209 

tip of the Spinous process of the fifth himbar 
vertebra (Fig. 153). 

At a point 3;^ centimeters below on the same 
Hne will be found the second foramen. Two and 
one-half centimeters further down is the third; 2 
centimeters down is the fourth, and i^ belo\\ 
this is the fifth. The first is about 35 mm. from 
the median line; the second, 30; the third, 25; the 
fourth, 20, and the fifth, 15 mm. 

TecJuiique of the Injections. — The spine is 
painted with iodine, which is then removed with 
alcohol. With a fine needle five dermal wheals 
are injected on each side of the median line at 
points overlying the sacral foramina. One com- 
mences at the top with a needle 9 centimeters 
long; if it does not at once enter the foramen the 
operator will readily find the opening by feeling 
about with the point of the needle. The latter 
should penetrate to a depth of about 25 mm. for 
the first foramen; 20 mm. for the second; 15 mm. 
for the third; 10 for the fourth, and 5 for the 
fifth. Five mils of a i per cent, solution are to 
be injected at each opening. 

In feeling about with the point of the needle, 
seeking the opening, the operator will suddenly 
sense the absence of resistance as the needle en- 
ters the foramen, and at the same moment the 
patient is likely to complain of a disagreeable sen- 
sation in the abdomen or legs which is proof that 
the nerve has been struck. After fifteen minutes 
the operation can be begun. The anesthesia lasts 
from one and one-half to two hours. 

14 



210 



REGIONAL ANESTHESIA. 




Fig, 155, — Trans-sacral anesthesia of the pelvic organs and pelvic 
peritoneum. The two iliac crests should be felt for and the line AB 
marked out. The prominent postero-inferior spine is at C, and the 
sacral cornu at D (sacro-coccygeal articulation). C is placed slightly 
too high in the sketch. The reader will notice at his right the promi- 
nent postero-inferior spine exactly outside of the sacral foramen, S2. 
S3 is exactly outside of the sacral cornu. S2 and Si are separated by 
the width of the thumb, as are also S2 and S3. S4 and Sj are sep- 
arated by the width of the little finger; the former corresponds to the 
summit of the sacral hiatus. The sacral foramina are situated on a 
line starting from the sacral cornu 15 millimeters from the median 
line and ending at the line AB, 35 millimeters from the median line. 
Z, the lumbosacral hiatus, is at the same distance from S2 and from 
AB. XY corresponds to the 5th lumbar. These landmarks are utilized 
in posterior sacral anesthesia as well as in spinal anesthesia. 



GENITO-URINARY ORGANS AND RECTUM. 



211 



Sacral injections anesthetize the labia, pros- 
tate, bladder, rectum, anus, uterus, and skin of 
the posterior surface of the thigh. We use this 
method to do prostatectomies, extirpation of the 




Fig. 156. — Trans-sacral anesthesia. (Pauchet.) (Posterior land- 
marks: Fig. 155). CC, inter-iliac line. EB, BE, a trapezoid figure 
the base of which measures 8 centimeters and the summit, 3 centi- 
meters. The points BB correspond to the sacrococcygeal articulation 
and the cornua of the sacrum ; they are located 15 millimeters from 
the midline. The 5th sacral foramen is situated immediately outside 
of them. Ei, postero-inferior iliac spine (here shown a little high). 
The black dot between D and the line Ei, Ei should be at equal dis- 
tance from D and Ei, Ei, i.e., in the lumbo-sacral space or area of 
election for lumbar puncture. The distance separating each sacral 
foramen from the midline is also shown. The finger, T, shows that 
there is a finger-breadth of distance between the sacral foramina. The 
needle is entering foramen No. 4. 



212 



REGIONAL ANESTHESIA. 



rectum, radical cure of prolapsus uteri, all vesical 
operations, curettage of the uterus, and catheter- 
ization of the ureters in man (for tuberculosis, 
cystitis, etc.), but the parietal peritoneum is not 
sufficiently anesthetized to permit of a hysterectomy. 
(See also Figs. 220 and 221, p. 282.) 




Fig. 157. — Trans-sacral anesthesia in man. (Pauchet.) 
This permits of operating upon a cancer of the rectum, hemor- 
rhoids, prostatic adenoma, tumor of the bladder, amputation of 
the penis, etc. 

Operations upon the Bladder, 
suprapubic cystostomy. 
To perform a suprapubic cystostomy, the trans- 
sacral and hypogastric forms of anesthesia com- 
bined are necessar}^ For a cystostomy a lozenge 



GEXITO-URINARY ORGANS AND RECTUM. 



213 



is made the long axis of which corresponds to the 
lower half of the distance between the umbilicus 
and the pubis. The skin and muscles are infil- 
trated with the weak solution. The bladder is 
not anesthetized; but infiltration of the space of 
Retzius sufficiently diminishes its sensibility. One 




Fig. 158. — Trans-sacral anesthesia in woman. (Pauchet.) 
The gray area shows the region anesthetized by injection of 
the sacral nerves (pelvis and perineum). This enables the 
surgeon to operate upon cancer of the rectum, hemorrhoids, 
prolapsus uteri, or cystocele, and the obstetrician to use for- 
ceps without pain. 



should add an intravesical injection of 50 mils of 
a yi per cent, solution, allowed to remain during* 
fifteen or twenty minutes for a simple section and 
vesical exploration. The bladder is rendered en- 



214 



REGIONAL ANESTHESIA. 



tirely insensitive by the sacral injections, but the 
abdominal wall must be infiltrated in addition be- 
fore it is incised. 




Fig. 159. — Suprapubic cystostomy. (Pauchet.) The opera- 
tor makes two wheals, 1 and 2; then infiltrates the subcuta- 
neous cellular tissues for a thumb's width to the right and left, 
and the two recti abdominis. Through wheai 1, he injects the 
space of Retzius in order to desensitize the bladder. 



Operations upon the Testicles and 
Scrotum. 

The operator should first anesthetize the cord, 
then make a ring of anesthesia about the base of 
the scrotum, on both sides. A wheal is made 
over the external abdominal ring. With the left 
hand, the cord is held firmly over the pubis, a 
needle detached from the syringe inserted, the cord 



GENITO-URINARY ORGANS AND RECTUM. 



215 







Fig. 160. — Anesthesia of the testicle. (Pauchet.) Infiltra- 
tion of the cord by transfixion of it upon the pubis. In order 
not to miss the cord, the needle is pushed successively in two 
or three divergent directions. 




Fig. 161. — Anesthesia of the testicle. (Pauchet.) Infiltra- 
tion of the cord. The latter is pinched between the fingers 
through the skin, raised between two fingers, and injected. 



216 



REGIONAL ANESTHESIA. 



transfixed upon the pubis, then, after sHght with- 
drawal of the needle, 5 mils of the weak solu- 
tion injected; this infiltrates the cord. To make 
certain, the maneuver is repeated and the cord 
immobilized upon the pubis, transfixed, and infil- 
trated with 5 mils of the weak solution. Then, 



Vxx 




Fig. 162. — Operations upon the scrotum. (Pauchef.) A band 
of subcutaneous infiltration circumscribes its base. 



with the left index finger, the operator finds the exter- 
nal inguinal ring, introduces the needle from 6 to 
9 centimeters into the inguinal canal, and injects 
anew 10 mils of the weak solution. 

To anesthetize the scrotum, the operator should 
work all the way round its base, starting at the 
lower surface of the penis, and, passing around. 



GENITO-URINARY ORGANS AND RECTUM. 217 

infiltrate the subcutaneous tissue until he gets 
back to the starting point. He then passes in 
front of the perineum and in the genito-crural 
folds. The weak solution is sufficient; 50 mils, 
more or less, are required. 

Operations upon the Penis. 

If it is desired to effect merely a dorsal incision 
of the prepuce, with simple section of the frenum, 



Fig, 163. — Anesthesia of the prepuce by a coronal 
injection. (Pauchet.) 

the skin should be infiltrated in the median line 
by the "Reclus method" from the anterior aspect of 
the prepuce to the corona of the glans. One is 
thus enabled to slit the prepuce with scissors and 
suture the borders of the wound. A second in- 
jection being made at the level of the frenum, 
this may be split and one or two sutures taken 



218 



REGIONAL ANESTHESIA. 



in it. We favor this simple operation, rather than 
that of circumcision. 

If the operator wishes to do an ordinary cir- 
cumcision, amputate the penis, or operate upon a 
hypospadias, it will be necessary for him to insti- 
tute a total anesthesia of the penis in the follow- 
ing manner: A wheal is made at the right and 
left of the root of the penis, where the cord 




Fig. 164. — Anesthesia of the penis. (Pauchet.) Through 
two wheals an injection is made at first deeply up to the roots 
of the corpora cavernosa and the suspensory ligament, then 
under the skin in circular fashion. 



crosses over the horizontal ramus of the pubis. 
Through this wheal the needle is introduced up to 
the corpora cavernosa, under the suspensory liga- 
ment of the penis, and deeply around the penis. 
Forty mils of a ^ per cent, solution of procaine- 
adrenin are injected. This injection will anes- 
thetize the urethra, corpora cavernosa, 
penis, etc. 



glans 



GENITO-URIiXARY ORGANS AND RECTUM. 219 

Operations upon the Posterior Urethra. 

For suture of the urethra, urethrotomy, etc., 
a wheal is first made in front of the anus in the 
median line. Then, through this wheal, the ver- 
tical plane of tissue that separates the anus and 
rectum behind from the urethra, bulb, and pros- 
tate in front is infiltrated. The left index finger 
is placed in the rectum and with the right hand 
a 9-centimeter needle is taken and passed in in 
the median line, very high up between the pros- 
tate and rectum; the operator now injects while 
withdrawing it. He then begins anew, without 
wholly withdrawing the needle, and passes to the 
right and to the left, in order to infiltrate a space 
9 centimeters high and 2 or 3 wide. This plane 
separates the rectum and anus behind from the 
prostate and urethra in front. All the subcutane- 
ous cellular tissues and the muscles should be in- 
filtrated. 

Finally, it is necessary to infiltrate the plane 
of section corresponding to the incision in peri- 
neotomy for operations on the prostate. The op- 
erator may in this way go up as high as the 
neck of the bladder and the prostate with per- 
fect anesthesia. Yet, anesthesia by the sacral fora- 
mina is in every way preferable. 



220 REGIONAL ANESTHESIA. 

Operations upon the Prostate, 
prostatectomy. 

A choice may be made from one of the four 
following methods of anesthesia : 

1. Periprostatic infiltration through the bladder. 

2. Periprostatic infiltration through the peri- 
neum. 

3. Anterior sacral anesthesia. 

4. Posterior trans-sacral anesthesia. 

I. Periprostatic Anesthesia Through the Blad- 
der. — (a) The operator begins by anesthetizing 
the abdominal wall, as for a cystotomy, then the 
space of Retzius. The simple infiltration of these 
tissues yields a satisfactory anesthesia. The injec- 
tion must be carefully pushed into the entire 
thicknesses of the muscles, in order to be able to 
separate them without pain. 

\h) For anesthesia of the prostate, the blad- 
der having been opened, the operator takes a long 
curved needle (Legueu's) and passes through the 
mucosa of the bladder around the prostate, with 
the finger as guide. Approximately 150 mils of 
the weak solution of procaine-adrenin is used. 
Five or six minutes after this infiltration the op- 
erator may begin removing the prostate. 

2. Periprostatic Anesthesia Through the Peri- 
neum. — The operator, after having infiltrated the 
abdominal wall as in the preceding method for a 
suprapubic section, must anesthetize the tissues 
between the two ischia, comprising the skin and 
soft parts situated between the urethra in front, 



GENITO-URINARY ORGANS AND RECTUM. 



221 



and the rectum and anus behind. This form of 
infiltration is useful for all operations upon the 
perineum (see Fig. 165). 

To reach the prostate, the operator places his 
left index finger in the rectum in contact with the hy- 
pertrophied organ. With the right hand a 9- 
centimeter needle is introduced into the perineum 
and guided up toward the prostate by the aid of 




Fig. 165. — Anesthesia of the anterior portion of the perineum 
through a wheal in front of the anus. (Pauchet.) 

a finger in the rectum. When the needle has at- 
tained the periprostatic region, 50, 60, or 80 mils 
of the weak solution of procaine-adrenin are 
injected. 

3. Anterior Sacral Method. — This consists in 
infiltrating all of the concavity of the sacrum with 
a I per cent, solution. The needle should pass 
between the rectum in front and the sacrum be- 



222 REGIONAL ANESTHESIA. 

hind. The operator injects approximately 5 mils 
of procaine-adrenin opposite each one of the sacral 
foramina. It is unnecessary to inject the upper 
foramen (see Fig. 152 and detailed descriptions, 
including that of the trans-sacral method, at the 
beginning of this chapter). 

4. Trans-sacral Method. — The operator must 
be experienced before such an anesthesia will 
prove perfectly satisfactory, but after some ex- 
perience the trans-sacral method, which is by long 
odds the best, will be the one chosen. 

With this procedure, very little of the anes- 
thetic is required, and all that is needed in addi- 
tion is the injection of the anterior abdominal 
wall. 

Operations upon the Vulva and Vagina. 

The posterior half of the vulva is supplied by 
the sacral nerves; the anterior half, by the ilio- 
inguinal and genito-crurals. If the operation in- 
dicated is one of minor importance, it is best to 
anesthetize the vulva directly. Three wheals are 
made, a middle one in front of the anus, and 2 
lateral ones at the lower terminations of the labia 
majora. The soft tissues outside the labia majora 
are then infiltrated, thus completing the anesthe- 
sia (Fig. 166). 

Where it is desired to anesthetize the vesti- 
bule of the vagina, the above method is not suffi- 
cient. One must infiltrate with the weak solution, 
following a frontal plane, in the manner already 
described for a perineotomy in the male. To infil- 



GENITO-URINARY ORGANS AND RECTUM. 



223 



trate the recto-vaginal septum, a finger should be 
introduced in the vulva or rectum to guide the 9- 
centimeter needle. One then infiltrates after Rec- 
lus's method, using 100 mils of the solution. After 
this one may operate for a recto-vaginal fistula, 
perform a perineorrhaphy, etc. 





Fig. 166. — Anesthesia of the vulva and vestibule. (Pauchet.) 



LIBERATION OF THE VAGINA AND OF THE UTERUS 
PROLAPSE, COLPORRHAPHY, COLPOTOMY. 

The preceding methods may be sufficient; this 
simple infiltration, however, does not anesthetize 
the pelvic floor. The vaginal vault should be in- 
filtrated in addition. To do this, the cervix of the 
uterus is brought down until it shows at the vulva; 



224 REGIONAL ANESTHESIA. 

a 9-centimeter needle is introduced into the an- 
terior cul-de-sac, and 20 mils of solution injected 
between the bladder and the cervix (not under 
the mucous membrane). Another injection is now 
made under the urethral meatus, and this time 
right and left injections made on each side under 
the mucous membrane; 10 mils of solution are 
used. The cervix is pulled to the right and an 
injection made into the left lateral cul-de-sac, in- 
filtrating the base of the broad ligament, using 
15 mils. The operator begins anew on the right 
side, then introduces the 9-centimeter needle into 
the posterior cul-de-sac, between the vaginal mu- 
cous membrane and Douglas's cul-de-sac, injecting 
20 mils. The uterus is now released and the 
perineum infiltrated as previously described. In all 
at least 200 mils are necessary. 

A satisfactor}^ anesthesia is obtained in a pre- 
cise and simple wa}^ with the sacral method; but 
by this procedure no hemostasis is assured, while 
on the contrary, if infiltration is practised after 
Reclus's method, the operation is bloodless. In 
perineorrhaphy this is an advantage; from the 
anatomical point of view, however, the sacral 
method is more attractive, and we give it preference. 

Operations upon the Anus. 

The trans-sacral procedure is very satisfactory 
in operations upon the anus. The perineal infil- 
tration gives not only a good anesthesia, but also 
a perfect ischemia. All will agree that to extir- 



GENITO-URINARY ORGANS AND RECTUM 



225 



pate hemorrhoids without the loss of a drop of 
blood is ideal. For this reason, we give pref- 
erence to the Whitehead operation, and infiltrate 
at a distance around the anus and rectum when 
the operation is practised, as upon a cadaver. 

Four dermal wheals are made in a lozenge 
form, one in front of the anus, two laterally, and 




Fig. 167. — Anesthesia of the anal region through four 
wheals circumscribing the anus and at some distance from it. 
{Pauchet.) 



the last behind, not too close, two finger-breadths 
from the anal orifice (Fig. 167 and 169). Through 
these four points all the injections, using ^ per 
cent, solution, are made. Through the perineal 
wheal, the needle is introduced, at first perpen- 
dicularly to the surface, and afterward in a fan- 
shaped manner, right and left, each time 4 or 5 

15 



226 



REGIONAL ANESTHESIA. 



mils of the solution being injected deeply in the 
sphincter and under the skin. Through the lateral 
wheals fan-shaped injections are also made, paral- 
lel to the rectal walls, reaching the levator ani, 
and bathing the ischio-rectal fossae, the sphincter, 
and the subcutaneous and submucous tissues (Fig. 





Fig. 168. — Radiating injections through the lateral wheal. 
(Pauchet.) The figure shows the three positions in which the 
needle should be placed in order to infiltrate the entire mass of 
tissue with quinine through a single wheal. 



i68). Finally, a mass of tissue is also infiltrated 
behind the anus and rectum, in fan-shaped fashion. 
The rectum is completely surrounded by the in- 
filtration. 



GENITO-URINARY ORGANS AND RECTUM. 



227 




>D 



Fig. 169. — Radical cure of hemorrhoids by Whitehead's op- 
eration. (Pauchet.) Through wheals A, B, C and D, a band 
of tissue is infiltrated along the dotted lines. Through the 
same wheal deep radiating inje<:tions are then made in the 
sphincter and adipose tissue of the ischio-rectal fossa, com- 
pletely surrounding the ano-rectal cylinder. 




Fig. 170. — Peripheral infiltration with quinine for incision 
of fistula in ano. {Pauchet.) 



228 REGIONAL ANESTHESIA. 

At the close of the infiltration, when the latter 
has been successful, the sphincter is gaping. In 
a few minutes, dilatation, dissection and descent 




Fig. 171. — Anorectal segment laid open after extirpation. 
(Pauchet.) Trans-sacral anesthesia is employed. The cancer- 
ous tumor forms a hollow cylinder. 

of the mucosa, resection, and cauterization can be 
effected without pain and without hemorrhage of 
any account. According to the degree of stout- 
ness of the patient, 50 or 100 mils of the solu- 



GENITO-URINARY ORGANS AND RECTUM. 229 

tion are required. Beginners should place a fin- 
ger in the rectum to guide the needle. 

Operations for fistula in ano may be done 
under the same method of infiltration. 

Wt haAX often practised total extirpation of 
tJie rectum, with absolute anesthesia — always by 
the trans-sacral method. Infiltration is not suffi- 
cient. We practice the anterior or posterior 
method, according to the degree of stoutness of 
the patient. 



CHAPTER VII. 

ANESTHESIA OF THE EXTREMITIES. 

Reduction of Fractures or Dislocations — 
QuENu's Method. 

In 1907, Quenu recommended the use of local 
anesthesia for the reduction of fractures and dis- 
locations. 

The procedure consists in injecting in the 
vicinity of the fracture an anesthetic solution so 
that the bone ends are bathed with it, the seat 
of the fracture being thus rendered insensitive. 
The muscles simultaneously relax, and one may- 
proceed without pain to dress the wound, exam- 
ine the parts, reduce, practice radioscopy, etc. 
For dislocations, the injection is made into the 
synovial sac, then about the dislocated articula- 
tion and the insertion of the muscles surrounding 
it. The previously rigid limbs become supple and 
mobile, muscular contractions cease, and reduc- 
tion becomes easy and painless. A i per cent, 
or Yz per cent procaine-adrenin solution is in- 
jected, according to the stoutness of the patient. 

It will not be necessary to describe the pro- 
cedure for every type of fracture or dislocation, the 
technique of the injection being practically the 
same in all. The procedure is easy and devoid 
of risk if a fine needle is used. A point at 
which the skin is not distended, contused, or trau- 
(230) 



ANESTHESIA OF THE EXTREMITIES. 



231 



matized in any way should be selected. In juxta- 
articiilar fractures, the fracture and the joint 




Fig. 172. — Anesthesia for reduction of an elbow dislocation. 
(Pauchet.) The quinine-urea solution is injected in the syn- 
ovial sac of the articulation and infiltrates the insertions of the 
muscles about the joint. 



should be simultaneously injected. In the lower 
extremities this is the procedure of choice. In the 
upper, one may, with experience, instead, anes- 
thetize the brachial plexus. 



232 



REGIONAL ANESTHESIA. 



Upper Extremity. 
The upper extremity as a whole, below the 
shoulder, receives its sensory supply from the 
brachial plexus, which becomes united beyond the 
scaleni into a single, comparatively narrow, cord. 
The upper intercostal nerves contribute in supply- 




Fig. 173. — Anesthesia for fracture of the humerus. {Pau- 
chet.) The needle is introduced at the site of fracture and 
quinine-urea solution injected throughout the region. 

ing the axilla with sensation and also furnish a 
portion of the sensibility of the skin of the inner 
surface of the arm. The skin of the shoulder 
region is supplied by filaments from the supra- 
clavicular branches of the cervical plexus. 



ANESTHESIA OF THE EXTREMITIES. 233 



ANESTHESIA OF THE BRACHIAL PLEXUS BY WAY 
OF THE AXILLA HIRSCHEL. 

The arm is extended in strong abduction (Fig. 
174). With the left hand fixing the axiUary 
artery, the needle is introduced high up as far as 
possible under the pectoralis major, following the 
longitudinal axis of the arm. The injection is be- 
gun during the introduction of the needle in 
order to push aside and avoid wounding the blood- 




Fig. 174. — Infiltration of the brachial plexus by way of the 
axilla. (Pauchet.) Below the inferior border of the pec- 
toralis major, with the arm abducted, the needle is intro- 
duced toward the nervous trunks, in a direction parallel with 
the axis of the arm. 

vessels. With a few syringefuls of the solution, 
the median nerve is blocked above, and the ulnar 
further anteriorly. To reach the radial nerve, one 
must penetrate more deeply under the artery, al- 
most to the height of the insertion of the pec- 
toralis major. The artery is there surrounded 
with injections, and with proper caution injury to 
it or to the vein is avoided. Thirty or 40 mils of 
the 2 per cent, solution are used. 



234 



REGIONAL ANESTHESIA. 



ANESTHESIA OF THE BRACHIAL PLEXUS BY THE 
SUPRACLAVICULAR ROUTE KULENKAMPFF. 

The location of the plexus is well shown, with- 
in by the subclavian artery, the pulsations of 
which can easily be felt; below, by the first rib, 
and in front, by the clavicle. Figure 175 shows 
the direction of the first rib, the supraclavicular 
region being seen in profile. It ascends behind 




Fig. 175. — Blocking the nerve trunks of the upper extremity. 
(Pauchet.) A, scalenus posticus. 5^. apex of the pleura. C, 
omo-hyoid. D, point where the wheal should be made. E, 
subclavian artery. F, scalenus anticus. G, sterno-mastoid. 

the clavicle and at a right angle, and is an im- 
portant landmark, for it indicates the extreme 
point of penetration of the needle. The dermal 
wheal should be made at about the middle of the 
clavicle, where the first rib crosses it. The arch 
of the subclavian arter}/ should be identified; it 
also crosses the clavicle at about its middle. Be- 
yond lies the apex of the pleura, hidden by the 
plexus. Still further, at the external border of 



ANESTHESIA OF THE EXTREMITIES. 



235 



the sterno-cleido-mastoid, will be noticed the scale- 
nus anticus, as well as the omo-hyoid, ascending 
obliquely from the first rib, and which has been 
divided, in order the better to show the course 
of the rib. Figure 176 shows the parts as they 
present themselves after removal of the skin and 




Fig. 176. — Anesthesia of the upper extremity, (Pauchef.) 
A, omo-hyoid. B, brachial plexus. C, subclavian artery. D, 
scalenus anticus. E, sterno-cleido-mastoid. 



the superficial and deep fascia. The transversalis 
artery of the neck is seen crossing the nerve 
trunks closely superimposed. Figure 177 and those 
following show the direction the needle should 
take. According to the more or less oblique 
direction of the first rib from the spine to the 
sternum, the needle, if prolonged, should reach 
the spinous process of the second or the third 
dorsal vertebra. On the other side are shown 
the plexus, the artery, the insertion of the scaleni, 
and finally, immediately below the clavicle, the 



236 



REGIONAL ANESTHESIA. 



crescent constituted by the nerves surrounding the 
artery. A needle introduced close to the artery 
and properly directed should pass through the 
middle of the nerve plexus. Almost always the 
pulsations of the artery will be transmitted to it. 
The narrowness of the interval between the 
scaleni is also apparent. 




A 6 C 



Fig. 177. — Anesthesia of the brachial plexus. {Kulen- 
kampff.) Summit of the thorax. Direction of the needle to 
the left. To the right, relationship of the structures in the 
vicinity. A, subclavian vein. B, insertion of the scalenus an- 
ticus. C, subclavian artery. D, brachial plexus. E, insertion 
of the scalenus posticus. 



TECHNIQUE OF THE INJECTION. 

The patient should, if possible, be placed in 
the sitting posture (Fig. 1/8), and should be 
forewarned of the paresthesia radiating to the fin- 
gers that will occur when the needle touches the 
plexus, being requested to make known the moment 
w4ien it appears. The subclavian artery is now 
slightly palpated with the finger. Its pulsations 



OPERATIOx\S UPOiN THE EXTREMITIES. 



237 



are often visible, especially on the right side. 
Just outside of the point where the artery descends 
behind the clavicle, with a fine needle, a wheal is 
made, which will correspond without exception to 
the middle of the clavicle. The external jugular 
vein, often visible lower down, crosses the clavicle 




Fig. 178. — Supraclavicular anesthesia of the brachial plexus. 
(Kulenkampff.) The left index finger locates and protects 
the subclavian artery. Laterally to the artery and above the 
middle of the clavicle, (X), the needle is introduced in the 
direction of the spinous process of the third dorsal vertebra. 



at the same point. Through this wheal a fine 
needle 4 to 6 centimeters long is inserted and 
directed as if one desired to strike the spinous 
process of the second or third dorsal vertebra. The 
plexus is superficially situated under the aponeu- 
rosis. As soon as the needle strikes it, lancinat- 
ing pains occur in the fingers supplied by the 
median, w^hich is the most superficial, and the 



23S 



REGIONAL ANESTHESIA. 



radial, situated behind the median. If the first 
rib is encountered at a depth of from i to 3 
centimeters, the operator will know that he has 
missed and passed the plexus, as it is more super- 
ficially placed. If no paresthesia is produced, he 




Fig. 179. — Blocking the brachial plexus. (Pauchet.) The 
needle penetrates the skin above and close to the clavicle. It 
traverses the plexus at the level of the clavicle and its point 
touches the first rib. If the line of direction were prolonged it 
M^ould pass through the spinous process of the third dorsal 
vertebra. 



should try to provoke it by altering the position 
of the needle. Very often, fear of wounding the 
artery causes the operator to introduce the needle 
too far out. If blood comes from the needle, it 
is because a vein or artery has been pierced, and 



ANESTHESIA OF THE EXTREMITIES. 239 

its direction must be changed. The moment pares- 
thesia appears, the syringe is adapted to the 
needle and lO mils of the 2 per cent, solution 
injected. If paresthesia is produced only in the 




Fig. 180. — Blocking the brachial plexus. (Pauchet.) The 
needle is inserted just above the middle of the clavicle. The 
left index finger locates the pulsations of the artery and 
pushes it out of the way. Abduction of the arm to 45° (Louis 
Easy) lifts away the artery and forms a curve with its con- 
cavity directed upward. The needle points toward the spin- 
ous process of the third dorsal vertebra. It pastes through the 
plexus and strikes the first rib. 



territory of the median, part of the solution should 
be injected some millimeters more deeply. The 
needle should be slightly displaced and lo mils 
injected in the immediate vicinity. Under no 



240 REGIONAL ANESTHESIA. 

circumstances should the injection be made before 
production of the paresthesia. 

If unquestionable paresthesia has been obtained 
both in the territory of the median and that of 
the radial in from one to three minutes a com- 
plete motor and sensory paralysis will be estab- 
lished in the arm. Often one must wait from 
ten to fifteen minutes. If, at the end of this time, 
paralysis is not complete, 5 to lo mils of the 4 
per cent, solution may be injected. Success will 
then, however, be uncertain. After the injection, 
the tourniquet may be applied without pain. It is 
often useful, for after blocking of the brachial 
plexus the arm is habitually hyperemic, the vaso- 
motors being paralyzed as after section of the 
nerves. The motor paralysis always reaches the 
circumflex nerve; but its territory is only hypo- 
esthetized or uninfluenced. Other nerves, prob- 
ably filaments from the supraclavicular, take part 
in the innervation of this region. The anesthesia 
lasts from one hour and a half to three hours. 



ANESTHESIA OF THE BRACHIAL PLEXUS BY THE 
INFRACLAVICULAR ROUTE LOUIS BAZY. 

The brachial plexus assumes the shape of a 
fan, the axis of which is constituted by the 
seventh cervical nerve. The origin of this root 
is immediately below the anterior tubercle of the 
transverse process of the sixth cervical vertebra 
(tubercle of Chassaignac). It is found on a level 
with the inferior border of the cricoid cartilage. 



ANESTHESIA OF THE EXTREMITIES. 



241 



The tubercle of Chassaignac is, then, the first 
landmark. 

After grouping themselves around the seventh 
cervical, the other branches of the cervical plexus 




Fig. 181. — Infraclavicular anesthesia of the brachial plexus. 
(Panchet.) Amputation of the arm performed on the Meuse 
at a spot 6 kilometers from the firing line. The operating 
room had been set up by the ambulance orderlies. Surgeon : 
Sourdat. Assistant : Louet, auxiliary physician. The patient 
is looking toward the camera. 



become engaged in the space between the clavicle 
and the first rib, and afterward pass perpendicu- 
larly to the coracoid process. When the arm is 
abducted in such a way that the tangent passing 



16 



242 



REGIONAL ANESTHESIA. 




Line of cricoid 'mth Wceri/ica/ - 
Cricoid 



Fig. 182. — Anesthesia of the brachial plexus by the infraclavicular 
route. {Pauchet.) Observe that the cricoid cartilage corresponds to 
the transverse process of the sixth cervical (tubercle of Chassaignac). 
This tubercle may be found by palpation, and the assistant should 
place his Index finger there at the time of the injection. To the right, 
the coracoid process, and one fingerbreadth within it, the plexus. The 
operator introduces the needle here immediately below the clavicle and 
directs it toward the tubercle of Chassaignac. The arm having been 
abducted to 45°, the axillary artery is separated from the brachial 
plexus, drawn away by the two thoracic branches given off from its 
lower aspect. The artery rests on the first rib. 



ANESTHESIA OF THE EXTREMITIES. 243 

through the apex of the coracoid process strikes 
the tubercle of Chassaignac, this hne indicates ex- 
actly the direction of the brachial plexus, which 
is situated one finger-breadth below it. This line 
may be considered as the 'line of anesthesia," 
and the coracoid process constitutes the second 
landmark. In this position the arm forms with 
the trunk an angle of 45° (Fig. 184). The axil- 
lary artery, held against the arm by its acromio- 
thoracic branch, deviates from the brachial plexus, 
describing a curve with its concavity upward. As 
a result of this, the risk of wounding it is slight. 

TECHNIQUE OF THE INJECTION. 

The patient is placed upon the table, with his 
spinal column resting upon a cushion in such a way 
that his shoulders are arched, as though for liga- 
tion of the subclavian or axillary under the clav- 
icle. The arm, hanging and abducted to 45°, ren- 
ders the prominence of the coracoid more appar- 
ent, and the plexus more superficial. 

The operator places himself on the side to be 
operated upon, between the arm and the trunk. 
He locates the apex of the coracoid and im^ 
mediately within it, with the left index finger, 
he depresses the soft tissues, as though wish- 
ing to make more apparent the prominence of the 
coracoid. 

Meanwhile the assistant identifies the tubercle 
of Chassaignac, over which he places his index 
finger. The arm being abducted to 45°, the in- 



244 



REGIONAL ANESTHESIA. 




Fig. 183. — Anesthesia of the brachial piexus by the infraclavicular 
route. (Louis Basy.) The two hands show the "line of anesthesia." 
The finger of an assistant is placed on the tubercle of Chassaignac; 
the surgeon's finger, inside of the coracoid process, which is shown by 
dotted lines. Here, within the finger tip, the needle enters immediately 
below the clavicle and is directed toward the brachial plexus. It is 
well to inject both upward, to the right, to the left, and deeply down- 
ward to be sure of reaching all the branches of the plexus. 



ANESTHESIA OF THE EXTREMITIES. 245 

dex finger of the operator and that of his assist- 
ant face each other, and the interval separating 
them marks the course of the plexus (Fig. 183). 
The line of anesthesia is now traced upon the 
skin with ^ per cent, procaine-adrenin solution. 

A needle 9 centimeters long is introduced in 
the zone of infiltration, almost immediately below 
the clavicle. The needle is pointed in such a way 
that it grazes the posterior border of the bone. 
When the needle has passed slightly beyond the 
upper surface of the clavicle, 10 mils of 2.5 per 
cent, procaine-adrenin solution are injected. The 
arm is flexed as if one wanted to place it upon 
the chest. As a result of this maneuver the bra- 
chial plexus is relaxed and comes in front of the 
needle, when it can be directly penetrated and 
anesthetized. 

Operations upon the Hand. 

The technique of anesthetizing a finger by 
means of injections all round it under the skin of 
the first phalanx has been well described by Rec- 
lus and is too well known to require description 
anew. The adjacent parts of the metacarpus may, 
however, be anesthetized consentaneously with the 
finger. 

ANESTHESIA OF A FINGER WITH THE ADJACENT 
PORTION OF THE METACARPAL. 

Two wheals are made upon the dorsal surface 
of the interdigital space, corresponding to its in- 



246 



REGIONAL ANESTHESIA. 




Fig. 184. — Landmarks for injection of the fingers. (Pau- 
chet.) The pyramid A shows the depth to which the needle 
is introduced, as ilkistrated in Fig. 187. 




Fig. 185. — Manner of holding the syringe in infiltrating 
palm by injection into the interdigital spaces. 



the 



ANESTHESIA OF THE EXTREMITIES. 



247 



ternal and external borders (Fig. 184). A J/^ or 
I per cent, solution is freely injected under the 
skin in the direction of points ^ or D in the 
palm, and i? or C in the back of the hand. Fig. 
185 shows the course of the needle in an injection 
in the palm through the interdigital space. The 
operation should not be started until the anes- 
thesia has reached the tip of the finger. 



DISARTICULATION OF THE MIDDLE FINGER OPERA- 
TION UPON THE THIRD METACARPAL BONE. 

Four wheals are made (Fig. 186), two in the 
interdigital spaces, and two metacarpal, over the 




Fig. 186. — Anesthesia of the medius with the head of its 
metacarpal; also anesthesia of the thumb with its metacarpal, 
(Paiichet.) 



interosseous spaces. The start is made at points 
3 and 4. Fig. 189 shows a section of the meta- 
carpus and the course followed by the needle. 



248 



REGIONAL ANESTHESIA. 




Fig. 187. — Infiltration of the palm of the hand through two 
injections from the dorsal aspect. (Pauchet.) 




Fig. 188. — Same as the preceding. 



ANESTHESIA OF THE EXTREMITIES. 249 

The tip of the left index finger being placed in 
the patient's palm, the needle is introduced at 3 
and 4, and the injection made perpendicularly 
through the interosseous space until the tip of the 
needle shows under the skin of the palm at B 
(Figs. 187 and 188). At each one of the two 




Fig. 189. — Anesthesia of a finger and its metacarpal bone. 
(Pauchet.) Longitudinal section of an interosseous space 
showing the different directions that the needle should take. 
1, deep palmar arch ; 2, superficial palmar arch ; 3, ulnar nerve ; 
4, palmar aponeurosis. 



injections 5 mils of the ^ per cent, solution are 
used. Next one infiltrates subcutaneously from 
points I and 2, in the palm toward point B, and 
upon the dorsum toward 3 and 4. Finally points 
3 and 4 are united by a subcutaneous injection. 
In all, from 30 to 40 mils of the ^ per cent, 
solution are required. 



250 REGIONAL ANESTHESIA. 

DISARTICULATION OF THE THUMB WITH 
ITS METACARPAL. 

The interosseous space is first injected, start- 
ing from point 6 and introducing the needle to 
point A under the skin of the palm (Fig. i86). 
Owing to the thickness of the soft parts, lo mils 
of the ^ per cent, solution are required. The next 
injection is made subcutaneously from points 5 and 
7 toward the palm in A, upon the back of the 
hand from 6. About 50 mils of the ^ per cent, 
solution are used. The thenar eminence may thus 
be anesthetized without piercing the skin of the 
palm, which is very sensitive. The same pro- 
cedure may be followed for the fifth metacarpal 
and finger. 

ANESTHESIA OF SEVERAL FINGERS WITH 
THEIR METACARPALS. 

Injections made at points i, 2, and 3 (Fig. 190) 
anesthetize the second and third fingers. From 
point 2 the injection is pushed in the interosseous 
space against point A, and from points i and 3 
in the palm toward point A. On the back of the 
hand one infiltrates under the skin toward point 2. 
Injections made at 4, 5, and 6 anesthetize the 
third and fourth fingers. Portions of the meta- 
carpus may be, as desired, circumscribed in the 
anesthetized territory, according as the points of 
entry 2 or 6 are placed nearer the fingers or the 
wrist. About 50 mils of J^ per cent, solution 
are required. 



ANESTHESIA OF THE EXTREMITIES. 



251 




Fig. 190. — Anesthesia of two fingers with the heads of the 
metacarpal bones. (Pauchet.) 




Fig. 191. — Anesthesia of one finger with the head of its 
metacarpal. (Pauchet.) Injections are made along the dotted 
lines through wheals at 1 and 2, circumscribing the region to 
be operated upon. 



252 



REGIONAL ANESTHESIA. 



ANESTHESIA OF THE SOFT PARTS OF THE PALM. 

Any portion of the palm may be anesthetized 
by employing the same technique as already des- 




Fig. 192. — Anesthesia of a portion of the palm of 
the hand. (Pauchet.) 



\ 



a i^' iJ fi 





Fig. 193. — Lines of infiltration for minor operations upon 
the dorsal aspect of the hand. (Pauchet.) 



cribed for anesthesia of the thenar and hypothe- 
nar eminences, e.g., in disarticulation of the thumb. 
The needle should, however, always be entered 



ANESTHESIA OF THE EXTREMITIES. 253 

upon the borders of the hand and upon the dor- 
sal aspect of the interosseous spaces (Fig. 192). 
If it is desired to anesthetize the pahii above the in- 
dex finger (Figs. 191, 193), the wheals should be 
made at points i and 2. Through these two 
points; free injections are made toward point A 
in the palm, using 30 to 40 mils of the J/^ per 
cent, solution. In the case of phlegmons of the 
hand, one should not inject in the vicinity of the 
affected parts, but resort instead to anesthesia of 
the brachial plexus. 



ANESTHESIA OF THE SOFT PARTS OF THE 
BACK OF THE HAND. 

In anesthesia instituted for the treatment of 
wounds or for the extirpation of ganglions, cysts, 
and other tumors, the field of operation is sur- 
rounded with a ^ per cent, solution. Fig. 193 
shows the manner in which the infiltration should 
be conducted in different cases. All that is neces- 
sary is to surround three sides of the field in the 
form of a U, since the nerves descend from the 
forearm exclusively. The anesthesia reaches the 
periphery by reason of the injection of three sides 
and in some cases extends beyond it below the 
field of operation. If the injections be made first 
under the tendons, and then under the skin, the 
anesthesia will include tissues beneath the fascia. 



254 REGIONAL ANESTHESIA. 

ANESTHESIA OF THE ULNAR NERVE 
AT THE ELBOW. 

The ulnar nerve is ordinarily palpable above 
the epitrochlea, where it can be made to roll under 
the finger. In anesthesia it is fixed with the 
thumb and index finger of the left hand and the 
needle is pushed up to it through the subcuta- 
neous tissues and fascia. The moment the nerve 
is touched, the patients will feel and complain of 




Fig. 194. — Section of the forearm above the wrist. (Pauchet.) 
1, Palmaris longus. 2, Median nerve. 3, Ulnar nerve. 



the same tingling as is experienced when the 
nerve is compressed. The solution is then in- 
jected. It should be noted that in many patients 
the ulnar nerve, when the arm is flexed, is sit- 
uated not behind but in front of the epitrochlea, 
and passes behind only when the forearm is in 
extension. Anesthesia follows very quickly after 
the injection and involves the little finger, the hy- 
pothenar eminence, the ulnar border of the hand, 
and the fifth metacarpal. For disarticulation of 



ANESTHESIA OF THE EXTREMITIES. 



255 



the little linger and other operations in this 
region, there is no simpler procedure (Figs. 195 
and 196). 

ANESTHESIA OF THE ENTIRE FIAND. 

The hand receives from the forearm the ulnar, 
median and interosseous nerves, which are all 




Fig. 195. — Anesthesia of the uhiar nerve. (Pauchet.) The 
nerve trunk is infiltrated in the depression between the epi- 
trochlea and the olecranon process. 1. Ulnar nerve. 2. Fibrous 
arch. 3. Flexor carpi ulnaris. 



three subfascial, together with the endings of the 
radial, which are subcutaneous. Fig. 198 presents 
a perpendicular section of the forearm above the 



256 



REGIONAL ANESTHESIA. 




Fig. 196. — Anesthesia of the ulnar nerve at the elbow. (Pauchet.) 
Anesthesia has been induced by means of an injection of strong pro- 
caine-adrenin solution in the depression between the epitrochlea and 
the olecranon, as well as by a bracelet of subcutaneous infiltration at 
the bend of the elbow. Suture of the ulnar nerve has been com- 
pleted. The dissection of the nerve has been effected without any pain. 
The wound is sutured with silkworm gut. 



ANESTHESIA OF THE EXTREMITIES. 



257 




Fig. 197. — Points of introduction of the needle to reach the 
median and ulnar nerves above the wrist. The needle is 
pointed and the injections made in the direction of the arrows. 




Fig. 198. — Anesthesia of the hand. (Pauchet.) Transverse 
section of the wrist at the level of the inferior radiocarpal 
articulation. Xote the bracelet-like black line of subcutaneous 
infiltration. The arrows represent the deep injections intended 
for A, the median nerve, and C, the ulnar ner^-e. 1. Tendon 
of the palmaris brevis. 2. Tendon of the palmaris longus. 3, 
Tendon of the abductor longus pollicis. 4. Supinator longus. 
5. Flexor carpi ulnaris. 6. Ulnar artery. 7. Ulna. 8. Radius. 
9. Pronator quadratus. 10. Radial artery. 

17 



258 REGIONAL ANESTHESIA. 

wrist, showing the direction in which the needle 
should be pushed toward the median and ulnar 
nerves. To reach the median at this level, a 
wheal is made on the ulnar side of the tendon 
of the palmaris longus, and the needle pushed 
through the fascia under this tendon. The oper- 
ator attempts to touch the nerve with the needle 
point. When the patient complains of shooting 
pains, 5 mils of a 2 per cent, solution are in- 
jected. Next, 5 mils of the same solution are 
injected on the ulnar side of the forearm, above 
the pisiform and beneath the tendon of the flexor 
carpi ulnaris (Fig. 198). Finally, one infiltrates 
through two or three other points in ring fashion 
around the forearm — under the skin, then upon 
the dorsal surface under the fascia between the 
tendons, and up to the interosseous ligament, 
using 50 to 60 mils of a ^ per cent, solution. 
Complete anesthesia of the whole hand is ob- 
tained in from ten to fifteen minutes. This pro- 
cedure is simpler than intravenous anesthesia. 

Operations upon the Forearm. 

The skin and subcutaneous tissues of the fore- 
arm down to its lower third are exclusively sup- 
plied by long subcutaneous nerves that emerge 
from under the fascia above the elbow. Infiltra- 
tion of a transverse band of subcutaneous tissue 
on the forearm produces, therefore, an anesthesia 
that becomes more or less extensive below the 
level of injection, and when a circle of subcuta- 



ANESTHESIA OF THE EXTREMITIES. 



259 



neous tissue above or below the elbow is infil- 
trated, the anesthesia extends on all aspects to the 
lower third of the forearm. 

For operations upon the skin of the upper two- 
thirds of the forearm, the field of operation should 
be surrounded by injections disposed in the shape 




Fig. 199. — Anesthesia of the dorsal surface of the fore- 
arm and hand. (Paucliet.) 



of a U with its concavity directed downward, 
using the ^ per cent, solution (Fig. 199). The 
unilateral nerve supply of this region renders the 
muscular injection unnecessary if the operation is 
unilateral. 

In the lower third the injection should also be 
subfascial on account of the nerves that emerge 



260 REGIONAL ANESTHESIA. 

from within the forearm. Extensive areas upon 
the lower third of the dorsal aspect of the fore- 
arm may be anesthetized as follows: Two in- 
jections are made upon the borders of the fore- 
arm, indicated by the bony ridge of the radius and 
ulna (Fig. 199, 5). With a long needle the soft 
parts of the dorsal surface are infiltrated, begin- 
ning with the muscles, then the subcutaneous tis- 
sues transversally, with 40 or 50 mils of a ^2 
per cent, solution. From these two points the 
subcutaneous infiltration descends to the wrist and, 
if necessary, to the fingers. This procedure is 
useful for the treatment of severe wounds of 
the soft parts, the extirpation of tumors or cysts, 
tuberculosis of the tendon sheaths, etc. 

The procedure adapted for the lower half of 
the anterior surface of the forearm differs slightly 
by reason of the median and ulnar nerves. Two 
injections are made upon the sides of the forearm, 
and these are joined by infiltrating transversally 
close to the bone and the interosseous ligament 
at the start, and then in the subcutaneous tissue. 
It is useless to try to infiltrate the muscles sep- 
arately; this is almost impossible in any case, and 
the median and ulnar are not blocked. If the 
operative field is in the ulnar distribution, it is 
best to inject this nerve at the elbow. If it is in 
that of the median, then this nerve should be 
anesthetized at the upper extremity of the incision. 
Those well trained in anesthesia of the brachial 
plexus will give this procedure the preference — 
especially in phlegmons, operations on the bone. 



AxNESTHESIA OF THE EXTREMITIES. 261 

amputations and interventions upon the upper half 
of the forearm, and in fact, in all operations of 
importance below the shoulder. 

Operations upon the Elbow. 

A subcutaneous U-shaped infiltration with con- 
cavity downward, using 40 mils of a J^ per cent, 
solution, upon the dorsal surface of the elbow, 
and instituted through two wheals (Fig. 200), 
will permit of extirpation of the olecranon bursa. 
To suture a fractured olecranon, two additional 
injections are necessary, 3 and 4. One begins by 
injecting 20 mils of the ^ per cent, solution into 



Fig. 200. — Anesthesia of the elbow region. (Pauchet.) 

the articulation, below the external and internal 
condyles. Ten mils are injected under the tendon 
of the triceps in the muscles covering the ole- 
cranon, first inside and then outside, and finally 
the U-shaped subcutaneous injection is made. For 
an aseptic arthrotomy — as for the removal of for- 
eign bodies — 20 mils of the }^ per cent, solution 
are injected in the joint and the capsule and sub- 
cutaneous tissue infiltrated along the line of in- 
cision. To perform a resection or disarticulation, 
blocking of the plexus is necessary. 



262 



REGIONAL ANESTHESIA. 




Fig. 201. — Anesthesia of the upper extremity. (Pauchet.) 
A, Blocking of the brachial plexus, producing anesthesia of 
the entire upper limb. B, Anesthesia of the forearm and hand. 
C, Anesthesia of the hand only. The points 1, 2, 3, 2' and 3' 
are the wheals through which the subcutaneous bracelet of in- 
filtration is made. The needle employed to infiltrate deeply the 
nerve trunks is also introduced through them. 1, Anterior 
branch of the radial nerve. 2 and 2', Median nerve. 3 and 
3', Ulnar nerve. 



ANESTHESIA OF THE EXTREMITIES. 



263 



Operations upon the Arm. 

Local injections are here suitable only for 
superficial operations. A simple subcutaneous in- 
jection is insufficient by reason of the irregular 
and multiple branching of the nerves. A pyram- 




Fig. 202. — Anesthesia of the forearm and hand. (Pau- 
chet.) Transverse section at the elbow. Note the bracelet of 
subcutaneous infiltration marked by a heavy black line. A, 
Deep injection to the median nerv^e. B, Deep injection to the 
radial. C, Deep injection to the ulnar. 1, Tendon of the bi- 
ceps. 2, Supinator longus. 3, Pronator radii teres. 4, Exten- 
sor carpi radialis longus. 5, Flexor carpi ulnaris. 6, Brachialis 
anticus. 7, Brachial artery. 



idal injection of the operative field is always re- 
quired. To anesthetize the skin of the entire sur- 
face of the arm, as for Thiersch skin grafting, 
one infiltrates superficially all the subcutaneous tis- 
sue with a jA per cent, solution, as for the thigh. 



264 



REGIONAL ANESTHESIA. 



For extensive operations on the bones, amputa- 
tions, etc., the plexus is injected above the clav- 
icle (Fig. i8i). 

Operations upon the Shoulder. 

Large lipomas of the shoulder are easily re- 
moved after multiple infiltrations have been made 







Fig. 203. — Suture of a fracture of the clavicle. {Pauchet.) 
Through two injections the clavicle is surrounded, to any ex- 
tent necessary, with the anesthetic solution. 



all around them. The base of the tumor is 
reached with long needles, and the injections are 
connected with one another by bands of subcuta- 
neous infiltration. A }^ per cent, solution is 
used, and as much as 200 to 250 mils may be 
injected. 



ANESTHESIA OF THE EXTREMITIES. 265 

Operations on the shoulder are performed after 
anesthesia of the plexus. For shoulder disarticu- 
lation, the plexus has first to be infiltrated, and 
then the subcutaneous tissues at the root of the 
shoulder up to the acromion and through the 
axilla. The Yz per cent, solution is used. 

LOWER EXTREMITY. 

It is difficult to anesthetize the lower ex- 
tremity by local injections, as it receives its nerve 
supply from many different trunks. On the other 
hand, spinal anesthesia is very serviceable, and 
only a small amount of procaine-adrenin solution, 
4 or 5 centigrams, need be used. The injection 
is made directly into the spinal canal of the lum- 
bar region. In a large number of cases regional 
anesthesia is absolutely indicated, and succeeds ad- 
mirably. Thus, all operations on the foot — resec- 
tion, amputation, tenotomy, suture of the patella, 
operations for varicose veins, or on the inguinal 
lymphatics, etc., — may be performed with complete 
anesthesia by the regional method. We give pref- 
erence, however, to lumbar spinal anesthesia for 
all major operations, such as resection of the 
knee, resection of the hip, and amputation of the 
thigh. We probably practice three regional anes- 
thesias to every spinal. 

The external cutaneous nerve emerges from 
under the inguinal ligament immediately within the 
anterior superior iliac spine; it descends in an out- 
ward direction under the fascia lata, perforates 



266 



REGIONAL ANESTHESIA. 



the fascia, and supplies the skin. It can be 
reached two finger-breadths within and below the 
anterior superior spine (Figs. 204 and 205). 
The technique is as follows: A dermal wheal 




Fig. 204. — Injection of the external cutaneous nerve (1) 
and of the anterior crural nerve (2). (Pauchet.) 1, Point 
where the needle should be introduced to reach the external 
cutaneous; the injection is made in the direction of the arrow, 
beneath the fascia and skin. 2, Point of entrance of the needle, 
perpendicularly to the surface, to reach the anterior crural 
nerve. 

is made and the subcutaneous connective tissue 
so injected as to make a transverse band 5 or 6 
centimeters v/ide, parallel to Poupart's ligament. 
Five mils of the strong solution are then injected 
under the fascia, in the same direction as the sub- 
cutaneous infiltration. The middle of the infil- 



ANESTHESIA OF THE EXTREMITIES. 



267 



trated area should be situated two finger-breadths 
within and below^ the anterior superior spine. 




Fig. 205. — Anesthesia of the external cutaneous nerve. 
(Pauchet.) This nerve is reached at a point two finger- 
breadths within and below the anterior superior spine of the 
ilium. 



The anterior crural nerve is situated imme- 
diately outside of the femoral artery and is cov- 
ered by a fibrous band (ilio-pectineus). With the 
left hand the operator locates the pulsations of the 



268 



REGIONAL ANESTHESIA. 



femoral artery and pushes the latter inward. The 
needle is then introduced immediately outside the 
artery, just below Poupart's ligament. Where it 
comes in contact with a solid band of fascia, 
the latter is pierced and 5 mils of the strong 




Fig. 206. — x\nesthesia of the anterior crural nerve, (Pau- 
chet.) A, Spine of the pubis. B, Anterior superior iliac spine. 
C, Point half way between the two. The femoral artery is 
located with the finger. The needle is inserted one finger- 
breadth outside of it to reach the anterior crural nerve. 



solution injected while still advancing i centimeter 
deeper. The patient should show some muscular 
contraction in the thigh, proving that the crural 
nerve has been reached. The quadriceps is then 
immediately paralyzed. 

Infiltration of the above two nerves affords a 
broad zone of anesthesia which will permit of 



ANESTHESIA OF THE EXTREMITIES. 269 

the taking of Thiersch grafts from an extensive 
surface of skin. 

Infiltration of the great sciatic nerve is very 
difficult and uncertain. One may, however, suc- 
ceed in the following manner: Bearing in mind 
that the nerve is situated in the buttock at the 
midpoint of a line passing from the ischium to the 
great trochanter, two deep injections are made, 
the first at a distance of 2 centimeters outside of 
the tuberosity of the ischium, and the other 3 
centimeters within the great trochanter. Or, a 
single injection may be made at the intersection 
of a horizontal line passing through the upper 
border of the great trochanter, and a vertical line 
passing through the external border of the ischium. 
It is indispensable that the patient should experi- 
ence a painful sensation in the toes. As soon 
as this pain is felt 10 mils of the strong solution 
are injected. 

Babitzki proceeds as follows: The finger is 
introduced in the rectum, the lower border of the 
great sciatic notch identified, and its contents, i.e., 
the nerve, pushed outward while the right hand 
introduces the needle to meet the nerve. 

The lesser sciatic nerve passes below the glu- 
teal fold exactly in the middle of the posterior 
surface of the thigh, immediately beneath the fas- 
cia. It is, therefore, easily accessible. 

The obturator nerve is deeply situated. To 
reach it with any degree of certainty all of the 
proximal internal surface of the thigh should be 
infiltrated to a depth of 3 or 4 centimeters. 



270 REGIONAL ANESTHESIA. 

In operating on the great trochanter or the 
neck of the femur, desensitization of the nerve 
trunks of the lower extremity is not sufficient; one 
must also anesthetize the branches of the genito- 
crural and ilio-inguinal by infiltration of the skin 
surrounding the root of the extremity. 

Operations upon the Toes. 

The technique is the same as for the fingers 
(Figs. 208 and 209). In the case of the big toe, 
three injections are made, two on the lateral sur- 
faces and one in the middle of the dorsal surface. 



Fig. 207. — Anesthesia of a toe through three dorsal 
injections. (Pauchet.) 

A subcutaneous ring-shaped injection is made at 
the root of the member, and 4 or 5 mils of the 
strong solution injected. For the other toes, the 
injections are made in the inter digital spaces 
(Fig. 209). 

Great Toe — Operations for Ingrowmg Toe Nail 
or Bunion, Amputation. — In disarticulation of the 
toe or resection of the head of its metatarsal 
bone for hallux valgus, three wheals are made, one on 



ANESTHESIA OF THE EXTREMITIES. 



271 



the internal border of the foot, the second a dorsal 
one, above the first interosseous space, and the 
third in the first interdigital space. One injects 




Fig. 208. — Anesthesia of the great toe with the head of its 
metatarsal bone. (Pauchet.) 

in the interosseous space, as for the hand. The 
needle is inserted in this space until its tip touches 
the deep portion of the skin of the sole. Infiltra- 
tion is then conducted under the skin from i to 




Fig. 209. — Anesthesia of middle toe with the head of 
its metatarsal bone. (Pauchet.) 



3, following the dotted line (Fig. 208). Fifty 
mils of the \veak solution are needed. 

Third Toe. — Operations on the metatarsal (Fig. 
209). — Four wheals are made as in operations 



272 REGIONAL ANESTHESIA. 

Upon the hand — two on the dorsal surface of the 
interdigital spaces, and two on the dorsum of the 
foot above the second and third interosseous spaces. 
Through i and 2, anesthetic sohition is injected 
in the interosseous space until the point of the 
needle is perceived under the skin of the sole, 
then the injection is continued under the skin of 
the dorsum toward i and 2. Fifty mils of the 
weak solution are required. 




Fig. 210. — Tenotomy of the tendo Achillis. (Pauchet.) 
TENOTOMY OF THE TENDO ACHILLIS. 

A wheal is made on each side, a subcutaneous 
diamond formed as shown by the dotted lines in 
the illustration (Fig. 210), then infiltration prac- 
tised under the tendon itself. 

Operations upon the Entire Foot. 

The foot is supplied by five trunks: The an- 
terior and posterior tibial, the internal and ex- 
ternal saphenous, and the musculo-cutaneous (Fig. 



ANESTHESIA OF THE EXTREMITIES. 



273 



211 ). The posterior tibial nerve is injected at 
the inner malleolus, i centimeter from the tendo 
Achillis (Fig. 211; note the direction of the 
needle). The needle is introduced from behind 
forward up to the posterior surface of the tibia. 




Fig. 211. — Nerves to be infiltrated in anesthetizing the en- 
tire foot. (Pauchet.) Section of left leg above the malleoli. 
For the anterior and posterior tibial a deep injection is neces- 
sary, and a subcutaneous bracelet for the other nerves, viz., 
the external and internal saphenous and the musculo-cutaneous. 



The Operator feels his way until he produces a 
lancinating pain, and then injects 5 mils of the 
strong solution. The other Avheals are made at 
the same level around the leg. A subcutaneous 
bracelet is infiltrated, using 50 to 75 mils of the 
weak solution, and the strong solution injected to 



274 



REGIONAL ANESTHESIA. 



block the anterior tibial, along the line for liga- 
tion of the artery of the same name. The re- 
sulting anesthesia is sufficient for resections and 
amputations in the infant and adult (Fig. 212). 




Fig, 212. — Anesthesia of the entire foot. (Pauchet.) 
Horizontal section of left leg above the malleoli. 1, Tibialis 
anterior. 2, Extensor proprius hallucis. 3, Extensor communis 
digitorum. 4, Tibialis posterior. 5, Tendo Achillis. 6, Flexor 
proprius hallucis. 7, Lateral peronei. The black band repre- 
sents a bracelet of subcutaneous infiltration. A, Deep injection 
for the anterior tibial nerve. B, Deep injection for the pos- 
terior tibial nerve. 



Operations upon the Knee. 

For a hygroma of the prepatellar bursa, four 
wheals are made (Fig. 213), and the subcutane- 
ous cellular tissue in the interval then infiltrated. 



ANESTHESIA OF THE EXTREMITIES. 



275 



This procedure is also adapted for the suture of 
a fractured patella. The prepatellar fibrous tis- 
sues and the articular cavity itself are infiltrated 
in the same way with the strong solution. In 
suture of the patella, however, 150 to 200 mils of 
the weak solution are used; the greater part of 
the solution runs out after the incision. 

For foreign body in the knee, the foreign body 
is first located with the fingers. Then, through a 




Fig. 213. — Removal of the prepatellar bursa. (Pauchet.) 



dermal wheal, a needle is introduced, followed by 
two or three more, to immobilize the foreign 
body. The skin overlying it is now infiltrated, 
the fascia likewise, an incision made, the foreign 
body removed, and the wound sutured. The oper- 
ation is brilliant, rapid, and painless. 

By the same procedure a transverse arthrot- 
omy, with section of the ligamentum patellae and 
the lateral ligaments, can very readily be per- 
formed. We have in this way removed projec- 



276 



REGIONAL ANESTHESIA. 



tiles embedded in the femoral condyles. Resection 
of the condyles can also be done in this way 
where the subject is not too stout; but for this 
operation we prefer spinal anesthesia. The weak 
solution suffices in all cases. 




Fig. 214. — Infiltration of a mass of tissue for arthrotomy 
of the knee, 1 and 2. (Pauchet.) Above, anesthesia of a seg- 
ment of vein. 



OSTEOTOMY OF THE FEMUR. 

Supracondylar and subtrochanteric osteotomies 
may be practised under local anesthesia by in- 
filtration. On the outer surface of the thigh, at 
a height of lo centimeters, a subcutaneous and 
then a subfascial band is traced. Next the mus- 
cular mass is infiltrated, down to the bone. Fin- 



ANESTHESIA OF THE EXTREMITIES. 277 

ally and still by the same route, a long needle is 
introduced in front of and outside of the bone, 
and the tissues freely infiltrated. The resulting 
anesthesia is perfect, the only steps in the opera- 
tion that are disturbing to the patient being the 
breaking of the femur or the blows of the mallet. 
The same difficulty is experienced in all bone op- 




Fig. 215. — Section of the thigh through its lower fourth. 
(Pauchet.) Manner in which the injections should be directed 
for an osteotomy of the femur. 



erations. Section of a rib or the removal of a 
cranial flap are alike painless manipulations, but 
the patient must be warned beforehand of the 
sounds caused by section of bone tissue. 



Operations upon the Soft Parts of the Thigh. 

The subcutaneous cellular tissues above the 
lesion are infiltrated in order to block the sub- 
cutaneous nerves. Next, one infiltrates in front 



278 



REGIONAL ANESTHESIA. 




Fig. 216, — Extensive subcutaneous infiltration through 
a series of wheals. (Pauchet.) 



ANESTHESIA OF THE EXTREMITIES. 



279 



and behind, and when necessary, below. This 
constitutes our routine practice for operations on 
varicose veins or for inguinal lymphatic enlarge- 
ments (see Figs. 216 and 217). The operation 
succeeds very well, but a large amount of the 




Fig. 217. — Peripheral infiltration of an inguinal lymph- 
node for adenitis. (Pauchet.) 



weak solution is required; this entails no danger, 
for a large portion of the solution runs out 
through the incision. In the removal of varicose 
veins we have commonly used 200, 250, and even 
300 grams of the weak solution, which is largely 
eliminated when the wound is irrigated with hot 
saline solution. 



280 



REGIOXAL ANESTHESIA. 




ANESTHESIA OF THE EXTREMITIES. 



281 




B 

< 

bi) 



2^2 



REGIONAL ANESTHESIA. 





Figs. 220, 221. — Sacral anesthesia of the lower extremity. (Pau- 
chet.) The sacral trunks, 1 to 4, require to be injected if one is to 
obtain the areas of anesthesia shown in the sections vS. Sections Lj 
and L4 show the anesthesia obtained by paralumbar injection. Sacral 
anesthesia of the genital organs is conducted through the third fora- 
men. The skin is anesthetized. The reader will note the numbers of 
the sacral trunks that must be injected to obtain the desired anesthesia. 



CONCLUSIONS.! 



Regional anesthesia may be availed of in 80 
per cent, of surgical operations. Its success de- 
pends upon the ability and experience of the oper- 
ator, but the disposition and mental attitude of 
the patient also play an important part. 

Wt invite beginners to use it not only in one 
type of case, but systematically in all cases, hold- 
ing themselves in readiness to use ethyl chloride 
to complete the work where necessary. 

Cranial nerve anesthesia and the paravertebral, 
brachial plexus, and trans-sacral procedures, which 
are most efficacious, require actual training. If 
our advice to learners is followed, this should not 
take a long time. Take a hat pin and a skeleton 
and practice introduction into the cranial fora- 
mina, as well as into the paravertebral and sac- 
ral openings, in accordance with the landmarks 
mentioned in this book. Such practice will re- 
quire one or tw^o hours. The same experimenta- 
tion should then be carried out upon a cadaver. 
This will also require about two hours of practice. 

After these two series of experiments, trials 
may be made upon the living subject. 

For the remaining operations, trials should be 



1 Pauchet-Sourdat-Laboure: Anesthesie regionale — Doin, publisher, 
Paris, 1917. 

(283) 



284 CONCLUSIONS. 

made with the book by one's side, as is done by 
the internes in my service. 

Be gentle, patient, and persevering in spite of 
failures and the aversion of certain patients, and 
you will succeed, with signal benefit to most cases 
and with general advancement of surgical practice. 



INDEX. 



Abdomen, anesthesia of, 128, 132, 
144, 162, 175, 220 
exploration of, 162 
Abdominal incision, transverse, 
164 
wall, anesthesia of, 132, 144, 
175, 220 
infiltration of, 162 
Abscess, interlobar, 158 
of lung, 158 

operation for. See Phlegmons, 
subphrenic, 158 
Adamantoma of lower jaw, 123 
Adenitis, cervical, 119, 122 

inguinal, 265, 279 
Adenoma of breast, 160 

prostate, 212 
Adrenin, use of, 14, 16 
Ala nasi, anesthesia of, 69, 99 
Alveolar process, superior, anes- 
thesia of, 69 
Anal fistula, incision in, 227, 229 
sphincter, anesthesia of, 226, 
227 
Anesthesia, Bazy's method of, 240 
circular, 25, 26, 88, 89, 99 
costoiliac, 175 
infiltration, 17, 21, 32 
by layers, 29 
deep, 29 

general technique of, 17 
perineal, 224, 225 
skin wheals in, 21 
subcutaneous, 25 
surface, 25 
intraspinal. See Spinal. 
Kulenkampff's method of, 234, 
235, 236 



paracostal, 175 
parailiac, 175 

paravertebral, 144, 163, 190, 
283 
cervical, 121-123 
dorsal, 144-147, 153, 158, 161, 

190, 198, 199 
lumbar, 150, 168, 169, 190, 
198, 199 
pericostal, 153 
presacral. See Sacral, 
regional, See Regional Anes- 
thesia, 
sacral, 202, 207, 282, 283 
anterior, 202, 204, 205, 221 
pre-, 202, 204, 205, 221 
trans-, 203, 204, 207, 210-212, 
219, 222, 224, 229, 283 
spinal, 128, 133, 135, 136, 265, 
276 
complications of, 133 
indications for, 128, 265, 276 
mortality in, 134 
regions influenced in, 135 
transsacral. See Sacral. 
Anesthetics for regional anes- 
thesia, 14, 15, 16 
Anterior crural nerve, 266-268 
Anterior sacral anesthesia, 205, 

221 
Anterior tibial nerve, 272-274 
Antrum of Highmore, anesthesia 

of, 70, 83 
Anus, anesthesia of, 132, 182, 211, 
224, 225 
trans-sacral, 224 
artificial, 182 
operations on, 224 

(285) 



286 



INDEX, 



Anus, perineal infiltration in oper- 
ations on, 224, 225 

Appendectomy, 143, 163, 169, 170, 
171, 175, 176 

Arm, anesthesia of, 232, 240, 241, 
258-264 
amputation of, 241, 261, 264 

Armamentarium for regional an- 
esthesia, 12, 14 

Arthrotomy of elbow, 261 
knee, 275, 276 

Ascending colon, operation on, 175 

Ascites, evacuation of tubercul- 
ous, 167 

Asepsis in regional anesthesia, 18 

Auditory meatus, anesthesia of 
external, 87 
furuncle in, 88, 91 
exostosis in, 88 

Auriculo-temporal nerve, 88 

Auricular branch of pneumogas- 
tric, 88 

Axilla, anesthesia of, 153, 162 

Babitski's method, 269 

Base of the orbit, 58 

Bazy's method, 240 

Biliary passages, anesthesia of, 

140, 141, 144, 145, 199 
Bladder, anesthesia of, 211-213, 
219 

exploration of, 213 

operations on, 212 
Bonain's solution, 86, 99 
Brachial plexus, anesthesia of, 
233-236, 253, 260, 261, 265 

Bazy's method, 240 

by way of axilla, 233 

infraclavicular, 240 

Kulenkampff's method, 234-236 

supraclavicular, 234-236, 264 
Brain tumors, removal of, 82 
Breasts, operations on, 145, 160, 
161 



Broad ligament, infiltration of 

base of, 224 
Buccal nerve, 72 
Buccinator nerve, 96 

gingival branches of, 96 
Bunion, operation for, 270 
Bursa, olecranon, removal of, 261 
Bursitis, prepatellar, operation 
for, 274-275 

Cancer of breast, 161 

floor of mouth, 106, 107 

ileocecal segment, 170 

jaw, 104 

larynx, 122 

palate, 54 

pharynx, 107 

rectum, 163, 212, 213, 229 

stomach, 182 

tonsils, 54, 107 

uterus, 136, 168 
Canine fossa, infiltration of, 83 

teeth, anesthesia of, 69, 95, 96 
Carotid artery, ligation of exter- 
nal, 119 
Cataract operation, 93 
Catheterization, anesthesia for, 

212 
Cecostomy, 170, 172, 175 
Cecum, anesthesia of, 145, 163, 
170-172, 175 

operations on, 163, 170-172, 175 
Celiotomy, supraumbilical, 65, 167 
Cerebellum, exposure of, 46 
Cervical adenitis, 119 

nerve roots, infiltration of, 109 

plexus, anesthesia of. 111, 119 
Cesarean section, 168 
Chassaignac's tubercle, 240, 241, 

243 
Cheek, anesthesia of, 66, 99, 107 

transverse incision of, 107 
Chin, anesthesia of, 101 
Cholecystectomy, 199 



INDEX. 



287 



Cholecystotomy, 129 
Choledochotomy, 163 
Ciliary ganglion, anesthesia of, 91 

nerves, 92 
Circular anesthesia, 25, 26, 88, 89, 

99 
Circumcision, 218 
Clavicle, suture of fracture of, 

264 
Colon, ascending, operations on, 
163, 175 

transverse, 179 
Colporrhaphy, 223 
Colpotomy, 223 
Compound skull fracture, 40 
Condyles of femur, 275 
Cord, spermatic, anesthesia of, 

197, 214, 215 
Corpora cavernosa, anesthesia of, 

218 
Costal resection, 153-157 
Costo-chondrites, suppurative, 158 

iliac anesthesia, 175 
Couzard and Chevrier, 117 
Cranial operations, 37 
Craniectomy for sarcoma, 39 
Crile, 17 
Curettage, aural, 91 

uterine, 212 
Cutaneous nerve, external, 265- 

267 
Cyst of dorsum, 253 

floor of mouth, 106, 107 

sternum, 143 

uterus, 212 
Cystocele, 213 
Cystotomy, 168, 211 
Cystotomy, suprapubic, 212, 214 

Danys, 114, 142 
Decompression, 43 
Decortication of kidney, 198 

lung, 158 
Deep infiltration, 29 



Dental branches, infiltration of, 95 
nerves, 70, 75, 94, 96, 103 
by buccal route, 70 
by external route, 70 
Disarticulations, 136, 247, 250, 

254, 261, 265, 270 
Dislocations, reduction of, 230, 
231 
Quenu's method of, 230 
Dorsal nerves, 137, 139, 144, 146, 

163 
Dorsum of hand, 253, 259 
Duodenum, 175 

Ear, anesthesia of, 85-88, 90, 91 

drum, puncture of, 86, 91 

external, 88, 90, 91 

middle, 86 
Elbow, anesthesia of, 254-256, 260, 
261 

arthrotomy of, 261 

disarticulation of, 261 

dislocation of, 231 

removal of foreign bodies in, 
261 

resection of, 261 
Empyema, thoractomy for, 153, 

156, 157 
Endolaryngeal operations, 118 
Endoneural injection, 34, 35 
Enterorrhaphy, 182 
Enterostomy, 170 
Epidural hematoma, 43 
Ethmoidal nerves, 81-84, 93 

sinus, 62 
Eventration, post-operative, 188 
Excision of joints. See Resection. 
Exostosis, 88 
External auditory canal, 87 

cutaneous nerve, 265-267 

saphenous nerve, 272, 273 
Extremities, anesthesia of, 132, 
230. See also Arm, Fore- 
arm, etc. 



288 



INDEX. 



Eye, anesthesia of, 69, 91, 93 
Eye ball, enucleation of, 92, 94 
Eyelids, operations on, 93 

Face, anesthesia of, 48, 97 
and neck, sensory nerve sup- 
ply of, 53 
Facial operations, 89, 97, 101 
Femoral arch, 198 

hernia, 195-198 
Femur, operations on neck of, 270 
osteotomy of, 276, 277 
resection of condyle of, 275 
spinal anesthesia in resection of, 
136 
Fibroids of uterus, hysterectomy 

in, 168 
Fingers, anesthesia of, 245, 247, 
249-251, 254 
disarticulation of, 247, 250, 254 
Fistula in ano, 227, 229 
intestinal, 170 
recto-vaginal, 223 
anesthesia of, 265, 270-273 
Foot, operations on, 129, 265, 272, 

273 
Foramen rotundum, anesthesia at, 

63, 66 
Forearm, anesthesia of, 260, 261 
Formulas, anesthetic, 15 
Fracture of skull, 40 
Fractures, reduction of, 104, 230, 

232, 261, 264 
Frenum, anesthesia of, 217 
Frontal nerve, 57, 60, 98 
Frontal region, anesthesia of, 98 
Frontal sinus, 62, 84 
Furuncle, anesthesia of, 36 
in auditory meatus, 88, 91 

Ganglion, removal of, 253, 260 
Gasserian ganglion, anesthesia of, 
48, PO 
injection of, 50 



Gastrectomy, 163-165, 184 
Gastric cancer. See Stomach, 

Cancer of. 
ulcer. See Stomach, Ulcer of. 
Gastroenterostomy, 162, 165, 166 
Gastrostomy, 165 
Genitalia, external, anesthesia of, 

200, 222 
Genito-crural nerve, 142, 189, 190, 

202, 222 
Genito-urinary organs, anesthesia 

of, 132, 141, 144, 167, 168, 

197, 200, 211-224 
Gingival branches of buccinator 

nerve, 96 
Glands, removal of, 119 
Glans penis, anesthesia of, 218 
Glosso-pharyngeal nerve, 106 
Goiter operation, 188, 122 
Grafts, Thiersch, 25, 263, 269 

Hallux valgus, operation for, 270, 

271 
Hand, anesthesia of, 245, 247, 
249-255, 258, 259, 262, 263 
infiltration of palm of, 246-248, 

252, 253 
phlegmon of. See Phlegmon. 
Hard palate, anesthesia of, 71, 72 
Harelip, operation for, 100 
Head and neck, anesthesia of, 48 
Heart, operations on, 141, 158 
Hematoma, epidural, 43 
Hemorrhoids, operations for, 129, 

212, 213, 225 
Hernia, femoral, 195-198 
inguinal, 175-188, 191, 193 
of the linea alba, 186 
of scrotum, 195 
umbilical, 186 
Herniotomy, 143, 175 
Hip, resection of, 265 
Hirschel's method of anesthesia, 
233 



INDEX. 



289 



Humerns, anesthesia of, 264 

fracture of, 232 
Hygroma of prepatellar bursa, 

274, 275 
Hypogastric anesthesia, 168 

plexus, 202 
Hypophysis, sarcoma of, 85 
Hypospadias, operation for, 218 
Hypothenar eminence, anesthesia 

of, 250, 252, 254 
Hysterectomy, 132, 168 
Hysteropexy, 164 

Ileocecal region, operations in, 
169 
resection, 169, 170, 172 
Iliac fossa, operations in, 169 
Ilio-hypogastric nerve, 142, 189, 

190, 193 
Ilio-inguinal nerve, 142, 189, 190, 

193, 202, 222 
Incision, median hypogastric, 167 

transverse abdominal, 164 
Inferior dental nerve, 75, 103 
larv-ngeal nerve, 117 
maxilla. See Jaw. 
maxillary nerve, 57, 12, 102, 
103, 125 
Infiltration anesthesia, 17, 21, 32, 

60, 61, 92, 115. 
Infiltration, of canine fossa, 83 
of cervical nerve roots, 109 
orbital, 60, 61, 92 
subconjunctival, 92 
Infraorbital nerve, 69, 82, 83, 93 
Infratrochanteric osteotomy of 

femur, 276 
Ingrowing toe nail, 270 
Inguinal canal, anesthesia of, 216 
Inguinal hernia, 175-188, 191, 193 
Ivmphatics, operations on, 265, 
279 
Inguino-crural region, anesthesia 
of, 170, 175, 189 



Injection at right angles, 22 

of nerves, 35 
Injections, circular, 26 

endoneural, 34, 35 

perineural, 34 

pyramidal, Zl 
Intercostal nerves, 137, 139, 142, 

147, 153, 158 
Interlobar abscess, 158, 159 
Internal pudic nerve, 200, 201 
Internal saphenous nerve, 272, 273 
Intestinal fistula, 170 

occlusion, 128, 136 

resection, 144, 162, 179 
Intestines, anesthesia of, 128, 132, 
136, 141, 144, 145, 162, 
172, 179 
Intradermal wheals, 21 
Intraorbital injections, 61 
Intraspinal anesthesia, 133 
Iridectomy, 93 
Ischio-rectal fossa, 226, 227 

Jaw, adamantoma of, 123 

cancer of, 104 

disarticulation of, 104 

fracture of, 104 

median section of, 102 
Jaws, anesthesia of, 97. 102 
Jejunostomy, 182 
Joints, anesthesia of, 231 
Jonnesco, 128, 132, 135 

Kidney, anesthesia of, 140, 141, 
144, 145, 198, 199 
operations on, 198 

Knee, operations on, 129, 265, 274- 
276 

Kulenkampff's method of anes- 
thesia, 234-236 

Labia, anesthesia of, 211 
Lachrymal gland, anesthesia of, 93 
nerve, 57, 60, 98 



290 



INDEX. 



Laminectomy, 152 
Laparotomy, 165, 167 
Laryngeal nerves, 106, 115-118 
Laryngectomy, 115, 122 
Laryngo-fissure, 118 
Laryngostomy, 118 
Laryngotomy, 115 
Larynx, cancer of, 122 
Le Filliatre, 128 

Leg, amputation of, 265, 280, 281 
Legueu's needle, 220 
Levator ani, anesthesia of, 226 . . 
Ligation of external carotid, 119, 
123, 124, 125 

thyroid artery, 119 
Limbs, anesthesia of, 230 
Linea alba, hernia of, 186 
Lingual nerve, 76, 11, 79, 105 
Lipoma of shoulder, 264 
Lips, anesthesia of, 69, 99, 100, 

101 
Liver, anesthesia of, 132, 141, 145, 

175, 199 
Luc's operation, 83 
Lumbar nerves, 138, 142, 144, 146, 

150 
Lung, abscess of, 158 

anesthesia of, 140, 141, 145, 158 

decortication of, 158 

tumor of, 158 

Malignant tumors. See Tumors. 
Mammary gland. See Breast. 
Mandible. See Jaw. 
Mastoidectomy, 90 
Mastoiditis, operation for, 90, 91 
Mastoid region, anesthesia of, 88 
Maxillary bones, resection of, 
102-104 
nerve, inferior, 57, 72, 102, 103, 
125 
superior, (iZ, 65, 66, 82-84, 94 
sinus, 70, 83 
Meatus, external auditory, 87 



Median hypogastric incision, 107 

nerve, 2ZZ, 257, 258, 260 
Medius, anesthesia of, 247 
Mental nerve, 79 
Mesenteric nerves, 179 
Mesentery, injection of, 144, 163, 

164 
Meso-appendix, infiltration of, 

171, 178 
Metacarpals, anesthesia of, 245, 

247, 249-251, 254 
Metatarsals, anesthesia of, 270, 

271 
Middle ear, 86 
Mid-frontal region, anesthesia of, 

98 
Molinar, 87 

Mortality risks of regional anes- 
thesia, 1 
of spinal anesthesia, 134 
Moure's operation, 82 
Mouth, floor of, anesthesia of, 105 

cancer of ,106, 107 
Mucous membranes, anesthesia of, 

2(i 
Musculocutaneous nerve, 272, 273 

Nasal cavities, anesthesia of, 80 

myxoma, removal of, 81 

nerve, 81, 98 

polyp, 81 

septum, resection of, 80 

wall, anesthesia of, 62 
Nasopalatine nerve, 81 
Neck, operations on, 109, 119, 121 

of bladder, anesthesia of, 219 

of femur, operations on, 270 
Needles for regional anesthesia, 

12 
Neocaine-surrenine, 14 
Nephrectomy, 129, 163, 198 
Nerve-blocking, 18, 35 
Nerves, anesthesia of. See In- 
dividual Nerves. 



INDEX. 



291 



Nose, anesthesia of, 69, 80, 99 
Novocaine-adrenalin, 14 

Obstetrical forceps, anesthesia for 

appHcation of, 213 
Obturator nerve, 269 
Offerhaus's measurements, 98 
Olecranon bursa, 261 

suture of, 261 
Ophthalmic nerve, 57, 60, 92 

frontal infiltration of, 60, 92 
Ophthalmology, anesthesia in, 91 
Orbital infiltration, 60, 61, 92 
Ossiculectomy, 86, 91 
Osteotomy of femur, 276 
Otology, regional anesthesia in, 85 
Ovary, anesthesia of, 141, 167, 
168 

tumor of, 167, 168 

Palate, anesthesia of, 54, 70-72, 
105, 108, 109 

and tonsil, cancer of, 54 
Palatine nerves, 70 
Palm of hand, infiltration of. 

See Hand. 
Pancreas, operation on, 164 
Paracentesis abdominis, 167 

thoracis, 153 
Paracostal anesthesia, 175 
Parailiac anesthesia, 175 
Paravertebral anesthesia. See An- 
esthesia, Paravertebral. 
Patella, suture of, 129, 265, 275 
Pauchet, 136, 186, 187 
Pelvic organs, anesthesia of, 200 
Penis, operations on, 212, 217, 218 
Pericardium, operations on, 158 
Pericostal anesthesia, 153 
Perineorrhaphy, 129, 223, 224 
Perineotomy, 219, 220 
Perineum, anesthesia of, 132, 200, 
221, 223, 224 

nerves of, 200, 201 



Perineural injection, 34 
Periosteum, anesthesia of, 30 
Periprostatic infiltration, 220 
Peritoneum, anesthesia of, 143 
Petromastoid operation, 90 
Pharyngotomy, 120 
Pharynx, cancer of, 107 
Phlegmons, anesthesia of, 36, 
253, 260 

of forearm, 260 

of hand, 253 
Pituitary, sarcoma of, 85 
Plastic operations, 36 
Pleurae, anesthesia of, 143, 145, 152 
Pleural cavity, paracentesis of, 

153 
Pleurotomy, 156, 157 
Pneumogastric nerve, 106 

auricular branch of, 88 
Polyp aural, 86 

nasal, 81 
Posterior nerves, anesthesia of. 
See Nerve, Anesthesia of. 
Post-operative eventration, 188 
Pre-patellar bursa, hygroma of, 

274, 275 
Prepuce, incision of, 217 
Pre-sacral anesthesia, 202, 204, 

205, 221 
Procaine-adrenin, 14 
Prolapsus uteri, 212, 213, 223 
Prostate, anesthesia of, 211, 219, 

220 
Prostatectomy, 129, 212, 220-222 

post-sacral anesthesia in, 222 

pre-sacral anesthesia in, 221 
Prostatic adenoma, 212 
Puncture for ascites, 167 

of pleural cavity, 153 

of tympanum ,86, 91 
Pus-tubes, 168 
Pylorectomy, 144, 180 
Pylorus, anesthesia of, 145, 180 
Pyramidal injections, 32 



292 



INDEX. 



Quadriceps extensor, anesthetic 

paralysis of, 268 
Quenu's method of anesthesia, 

230 
Quinine and urea hydrochloride, 

17, 144, 163, 164, 167, 171, 

178, 179, 188, 226, 227, 231 

Radial nerve, 233 
Reclus, 1, 20 

continuous injection of, 20 
Recto-vaginal fistula, 223 

septum, 223 
Rectum, anesthesia of, 132, 163, 
200, 211, 228, 229 

cancer of, 163, 212, 213, 229 

extirpation of, 132, 136, 212, 
213, 228, 229 
Recurrent laryngeal nerve, 117 
Regional anesthesia, 1, 17 

absence of danger of asphyxia 
in, 2 

adrenin in, 16 

advantages of, 1, 4 

anesthetics for, 14, 15, 16 

armamentarium for, 12 

asepsis in, 18 

disadvantages of, 5 

duration of, 4 

failures in, 7 

formulas used in, 15 

gentleness and skill in, 6 

indications for, 11, 128, 283 

injections in, 19, 22 

mixtures used in, 14 

mortality risks of, 1 

needles for, 12 

novocaine-adrenalin in, 14 

partial anesthesia in, 7 

post-operative dangers in, 2 

preparation of operative field 
in, 19 

procaine in, 16 

procaine-adrenin in, 14 



Regional anesthesia, psychology of 
patient in, 9, 283 
scopolamine-morphine before, 8, 

10 
shock in, 2 
syringes for, 12 
time element in, 9 
training required for, 5, 283 
unequal adaptability of, 10 
Regional anesthesia in cranial op- 
erations, Zl 
dental surgery, 94 
ophthalmology, 91 
otology, 85 
rhinology, 80 
of face and jaws, 97 
floor of mouth, 105 
ear, 85 

head and neck, Z1 , 48, 109 
nasal cavities, 80 
palate, 105 
teeth, 94 
thorax, 128 
tongue, 105 
tonsils, 105 
Resection, ileocecal, 169, 170, 172 

submucous, 80 
Resection of condyles of femur, 275 
costal cartilages, 155 
elbow, 261 
foot, 265 
intestine, 144 
knee,, 265 

maxillary bones, 102-104 
metatarsals, 270, 271 
nasal septum, 80 
omentum, 163, 188 
ribs, 143, 153, 154, 159 
Retromolar trigone, 76, 11 
Retzius, infiltration of space of, 

213, 214, 220 
Rhinology, anesthesia in, 80 
Ribs, anesthesia of, 152, 153, 158 
resection of. See Resection. 



INDEX. 



293 



Sacral anesthesia, 202, 283 
of genital organs, 282 
foramina, anesthesia through, 

207 
plexus, 200, 201, 222 
Salpingitis, 168 
Sarcoma of hypophysis, 85 
Scalp, tumor of, 38 
Sciatic nerve, great, 200, 201, 269 

lesser, 269 
Scopolamine-morphine, 8, 10 
Scrotum, anesthesia of, 195, 214- 
216 
operations on, 214 
Septal nerves, 81 
Septic buccal cavity, 96 
Septum, recto-vaginal, 223 
Serous membranes, anesthesia of, 

143 
Shoulder, anesthesia of, 264 
disarticulation of, 265 
lipoma of, 264 
Sinus, ethmoidal, 62 
frontal, 62, 84 
maxillary, 70, 83 
nasal, 62, 70, 83, 84, 85 
sphenoidal, 62, 85 
Skin-grafting, 25, 263, 269 

wheals, 21 
Skull wounds, anesthesia for, 40 
Space of Retzius, 213, 214, 220 
Spermatic cord, anesthesia of, 

197, 214, 215 
Sphenoidal sinus, anesthesia of, 

62, 85 
Sphincter ani, anesthesia of, 226, 

227 
Spinal anesthesia, 128, 133, 135, 
136, 265, 276 
column, anesthesia of, 152 
Spleen, anesthesia of, 140, 144 
Staphylorrhaphy, 109 
Sternum, anesthesia of, 143, 152, 158 
curettage of, 143 



Stomach, anesthesia of, 132, 141, 
145, 163, 165, 175, 180 
cancer of, 182 
operations upon, 163, 180 
resection of, 163, 164, 166 
ulcer of, 180, 181, 184 
Subconjunctival infiltration, 92 
Subphrenic abscess, 158 
Superior dental nerve, 70 
laryngeal, 116, 118 
maxillary, nerve, 63, 66, 82-84, 
94 
Supraclavicular fossa, 153 
Suprapubic cystostomy, 212, 214 
Symphysis menti, anesthesia of, 

101 
Syringes for regional anesthesia, 
12 

Teeth, anesthesia of, 69, 70, 94-96 

Tendo Achillis, 272 

Tendon sheaths, tuberculosis of, 

253, 260 
Tenotomy of foot, 265 
Testicle, anesthesia of, 141, 197, 
214, 215 

operations on, 214 
Thenar eminence, 250 
Thierry de Martel, 46 
Thiersch grafts, anesthesit for, 

25, 263, 269 
Thigh, amputation of, 265 

anesthesia of skin of, 211 

operations on soft parts of, 
277, 278 
Thoracic nerves, 136, 139, 144 

rigidity, 155 

walls, anesthesia of, 144, 153 
Thoracotomy, 143, 153, 156-158 
Thorax, anesthesia of, 128, 140, 

141, 143-145, 152, 153 
Thumb, anesthesia of, 247, 250 
Thyroid artery, ligation of, 119 
Thyroidectomy, 119, 121 



294 



INDEX. 



Tibial nerve, anterior, 272-274 
Toes, anesthesia of, 270, 271 
Toe nail, ingrowing, 270 
Tongue, anesthesia of, 79, 105- 

107, 122, 127 
Tonsillectomy, 108, 109 
Tonsils, anesthesia of, 105 

cancer of, 107 
Tracheotomy, 118 
Trans-sacral anesthesia, 203, 204, 
207, 210-212, 219, 222, 224, 
229, 283 
Transverse abdominal incision, 164 

colon, operations on, 179 
Trephining, 40, 42, 43 
Trochanter, operations on, 270 
Tuberculosis of ileo-cecal seg- 
ment, 170 

tendon sheaths, 253, 260 
Tuberculous ascites, 167 
Tumors, malignant, 26, 39, 42, 54, 
104, 106, 107, 122, 136, 
158, 161, 163, 168, 170, 
182, 212, 213 
Tumors of bladder, 212 

brain, 82 

breast, 160, 161 

cecum, 163 

colon, 163 

cranium, 39, 42 

dorsum, 253, 260 

forearm, 260 

hypophysis, 85 

ileocecal segment, 170 

jaw, 104, 123 

larynx, 122 

lung, 158 

mouth, 106, 107 

nasal cavities, 81 

neck, 119 

ovary, 167, 168 

palate, 54 

pharynx, 107 



Tumors of prostate, 212 

rectum, 163, 212, 213, 229 

scalp, 38 

shoulder, 264 

stomach, 182 

tongue, 106, 107, 122, 127 

tonsil, 54, 107 

uterus, 136, 168, 212 
Turbinates, removal of, 81 
Tympanum, anesthesia of, 86, 91 

Ulcer of stomach, 180, 181 
Ulnar nerve, 233, 254, 256, 257, 

260 
Umbilical hernia, 186 
Ureter, anesthesia of, 141, 144, 

212 
Ureteral catheterization, 212 
Urethra, anesthesia of, 218, 219 

suture of, 219 
Urethrotomy, 219 
Urocaine, 17 

Uterus, anesthesia of, 132, 141, 
168, 211, 214 

cancer or fibroids of, 136, 168 

curettage of, 212 

liberation of, 223 

prolapse of, 212, 213, 223 

Vagina, anesthesia of vault of, 
223 
vestibule of, 222, 223 
liberation of, 223 
Varicocele, 129 
Varicose veins, 265, 279 
Vesical exploration, anesthesia 
for, 213 
operations, 212 
Vestibule, anesthesia of, 87 
Vulva, operations on, 222, 223 

Wheals, 21 

Whitehead operation, 225, 227 







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